MEDICARE: KENNETH BALDEMOR REYES FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	95043997	CA
2	164X00000X	Licensed Vocational Nurse	223137	CA
3	363LF0000X	Family Nurse Practitioner	95018998	CA

General Provider Information

NPI Number	:	1083907547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH BALDEMOR REYES FNP-BC

Provider Business Mailing Address
First Line	:	438 CAMINO DEL RIO S STE 203
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3546
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	438 CAMINO DEL RIO S STE 203
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3546
Country	:	US
Telephone Number	:	619-955-8507
Fax Number	:	619-955-8508

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2011
Last Update Date	:	01/10/2025

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