Healthcare Provider Details

I. General information

NPI: 1093596215
Provider Name (Legal Business Name): KAYLA WALTERS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JOSEPH CT
SAN RAFAEL CA
94903-2664
US

IV. Provider business mailing address

4 CRESTA CIR APT 1
SAN RAFAEL CA
94903-5563
US

V. Phone/Fax

Practice location:
  • Phone: 415-785-4993
  • Fax: 415-599-4362
Mailing address:
  • Phone: 347-571-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number867881
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number760190
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number26NP07315100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: