Provider Demographics
NPI:1043065063
Name:RODRIGUEZ, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RODRIGUEZ
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 1:237 E CHANNEL ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2322
Mailing Address - Country:US
Mailing Address - Phone:209-444-8910
Mailing Address - Fax:209-444-8905
Practice Address - Street 1:237 E CHANNEL ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2322
Practice Address - Country:US
Practice Address - Phone:209-444-8910
Practice Address - Fax:209-444-8905
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program