Provider Demographics
NPI:1306529094
Name:LEWALLEN, KYLEE
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:LEWALLEN
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 1:32905 PASEO DEL AMOR
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4439
Mailing Address - Country:US
Mailing Address - Phone:949-357-9486
Mailing Address - Fax:
Practice Address - Street 1:22521 AVENIDA EMPRESA STE 116
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2046
Practice Address - Country:US
Practice Address - Phone:949-766-8535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist