Provider Demographics
NPI:1578233037
Name:BROWN, KAYLYNN KRISTINE
Entity Type:Individual
Prefix:
First Name:KAYLYNN
Middle Name:KRISTINE
Last Name:BROWN
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 1:7610 PINE RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8808
Mailing Address - Country:US
Mailing Address - Phone:909-261-7822
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-883-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant