Provider Demographics
NPI:1447977327
Name:TREVINO, KAITLYN ROSE (ACCNS-P)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:TREVINO
Suffix:
Gender:F
Credentials:ACCNS-P
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:ROSE
Other - Last Name:RADIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7313 NORMANDY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-5341
Mailing Address - Country:US
Mailing Address - Phone:616-915-7369
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-1814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096921364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics