MEDICARE: CAITLYN KENOBI DONART

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1316621899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAITLYN KENOBI DONART

Provider Business Mailing Address
First Line	:	180 STONEGATE RD
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-7575
Country	:	US
Telephone Number	:	805-827-3181
Fax Number	:

Provider Business Practice Location Address
First Line	:	1338 S GRAND AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90015-3009
Country	:	US
Telephone Number	:	213-389-5820
Fax Number	:

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

Provider Enumeration Date	:	06/14/2023
Last Update Date	:	06/14/2023

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