Provider Demographics
NPI:1801338645
Name:KOSTECKI, KAITLIN DARLENE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:DARLENE
Last Name:KOSTECKI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:KAITLIN
Other - Middle Name:DARLENE
Other - Last Name:HARTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1615 ORANGE TREE LN
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4501
Mailing Address - Country:US
Mailing Address - Phone:909-786-0725
Mailing Address - Fax:
Practice Address - Street 1:33758 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2243
Practice Address - Country:US
Practice Address - Phone:909-795-9747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily