MEDICARE: KENT IAN CABALLERO ROBIN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95028402	CA

General Provider Information

NPI Number	:	1295582435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENT IAN CABALLERO ROBIN

Provider Business Mailing Address
First Line	:	20656 WYANDOTTE ST
Second Line	:
City	:	WINNETKA
State	:	CA
Zip	:	91306-2749
Country	:	US
Telephone Number	:	323-519-8717
Fax Number	:

Provider Business Practice Location Address
First Line	:	21550 OXNARD ST FL 3
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7105
Country	:	US
Telephone Number	:	747-288-3543
Fax Number	:

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

Provider Enumeration Date	:	05/06/2024
Last Update Date	:	05/09/2024

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