Healthcare Provider Details

I. General information

NPI: 1083907547
Provider Name (Legal Business Name): KENNETH BALDEMOR REYES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 CAMINO DEL RIO S STE 203
SAN DIEGO CA
92108-3546
US

IV. Provider business mailing address

438 CAMINO DEL RIO S STE 203
SAN DIEGO CA
92108-3546
US

V. Phone/Fax

Practice location:
  • Phone: 619-955-8507
  • Fax: 619-955-8508
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018998
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95043997
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number223137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: