Healthcare Provider Details

I. General information

NPI: 1982523221
Provider Name (Legal Business Name): CASSIDY KOTRAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 TENNESSEE ST APT B
REDLANDS CA
92373-4490
US

IV. Provider business mailing address

91 TENNESSEE ST APT B
REDLANDS CA
92373-4490
US

V. Phone/Fax

Practice location:
  • Phone: 310-892-0910
  • Fax:
Mailing address:
  • Phone: 310-892-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95198962
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95040704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: