Provider Demographics
NPI:1003572579
Name:CONLON, CAITLIN PROVOST
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:PROVOST
Last Name:CONLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 S BUENA VISTA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4542
Mailing Address - Country:US
Mailing Address - Phone:818-557-2671
Mailing Address - Fax:
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:818-557-2671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018484363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily