Healthcare Provider Details

I. General information

NPI: 1942601281
Provider Name (Legal Business Name): PRATIBHA KAYASTHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 N MOUNTAIN AVE SUITE A
UPLAND CA
91786-8516
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-2228
  • Fax: 909-946-8007
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number827747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: