Provider Demographics
NPI:1164277638
Name:MOSTELLER, KORY LOGAN (LVN)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:LOGAN
Last Name:MOSTELLER
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12240 HESPERIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8309
Mailing Address - Country:US
Mailing Address - Phone:760-245-8837
Mailing Address - Fax:
Practice Address - Street 1:12220 HESPERIA RD STE A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5823
Practice Address - Country:US
Practice Address - Phone:760-245-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA267965164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse