Provider Demographics
NPI:1942601281
Name:KAYASTHA, PRATIBHA
Entity Type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:
Last Name:KAYASTHA
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 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:585 N MOUNTAIN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8516
Practice Address - Country:US
Practice Address - Phone:909-946-2228
Practice Address - Fax:909-946-8007
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA827747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily