Provider Demographics
NPI:1972127546
Name:KUYKENDALL, DYSTANY LEANN
Entity Type:Individual
Prefix:
First Name:DYSTANY
Middle Name:LEANN
Last Name:KUYKENDALL
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 1:1700 BROADWAY FL 59
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2141
Mailing Address - Country:US
Mailing Address - Phone:510-273-4200
Mailing Address - Fax:510-273-8340
Practice Address - Street 1:1700 BROADWAY FL 5 AND 9
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2141
Practice Address - Country:US
Practice Address - Phone:510-273-4200
Practice Address - Fax:510-273-8340
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25241Medicaid