Provider Demographics
NPI:1508681008
Name:BLONDEAUX, KYRA
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:BLONDEAUX
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S MENTOR AVE UNIT 138
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3326
Mailing Address - Country:US
Mailing Address - Phone:724-487-9192
Mailing Address - Fax:
Practice Address - Street 1:11645 WILSHIRE BLVD STE 1120
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6810
Practice Address - Country:US
Practice Address - Phone:877-650-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily