Healthcare Provider Details

I. General information

NPI: 1568357796
Provider Name (Legal Business Name): KAYLIE M BALVANEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 07/20/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 OLD CONEJO RD STE 200
THOUSAND OAKS CA
91320-2130
US

IV. Provider business mailing address

7268 MISSOURI ST
FONTANA CA
92336-0835
US

V. Phone/Fax

Practice location:
  • Phone: 805-298-7034
  • Fax:
Mailing address:
  • Phone: 909-681-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66563
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: