Healthcare Provider Details

I. General information

NPI: 1801703509
Provider Name (Legal Business Name): BRIELLE NICOLE KEATON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E REDLANDS BLVD STE. 215
REDLANDS CA
92373
US

IV. Provider business mailing address

12625 FREDERICK ST STE I5-176
MORENO VALLEY CA
92553-5216
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-1078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: