Provider Demographics
NPI:1417687096
Name:SOBREPENA, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:SOBREPENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10848 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-5003
Mailing Address - Country:US
Mailing Address - Phone:818-488-4840
Mailing Address - Fax:
Practice Address - Street 1:25000 AVENUE STANFORD STE 167
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4596
Practice Address - Country:US
Practice Address - Phone:818-488-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021299363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health