Provider Demographics
NPI:1013547447
Name:KITILYA, REDISTARD GEOFREY
Entity Type:Individual
Prefix:
First Name:REDISTARD
Middle Name:GEOFREY
Last Name:KITILYA
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 1:7891 EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3734
Mailing Address - Country:US
Mailing Address - Phone:909-973-0921
Mailing Address - Fax:
Practice Address - Street 1:7891 EL DORADO ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3734
Practice Address - Country:US
Practice Address - Phone:909-973-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118660164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse