Provider Demographics
NPI:1285288183
Name:REITNOUER, KEELEY BRIANNA (PA-C)
Entity type:Individual
Prefix:
First Name:KEELEY
Middle Name:BRIANNA
Last Name:REITNOUER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEELEY
Other - Middle Name:BRIANNA
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5849
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 4300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5330
Practice Address - Country:US
Practice Address - Phone:323-442-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant