Healthcare Provider Details

I. General information

NPI: 1750089116
Provider Name (Legal Business Name): KAYLA CHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27661 MAN O WAR DR
TEHACHAPI CA
93561-5355
US

IV. Provider business mailing address

PO BOX 220506
NEWHALL CA
91322-0506
US

V. Phone/Fax

Practice location:
  • Phone: 661-972-3787
  • 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 NumberY4221942
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberY4221942
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: