Provider Demographics
NPI:1962587717
Name:HENDRICKS, KYLA JEANNE (PA)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:JEANNE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:J
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:5720 RALSTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7844
Mailing Address - Country:US
Mailing Address - Phone:805-804-4168
Mailing Address - Fax:805-830-1177
Practice Address - Street 1:2525 ERRINGER RD
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2352
Practice Address - Country:US
Practice Address - Phone:805-527-1404
Practice Address - Fax:805-527-5246
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16030OtherPA STATE LICENSE
CAW268Medicare PIN
CAQ48475Medicare UPIN