Provider Demographics
NPI:1043097520
Name:KING, KIMBERLEY A
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:A
Other - Last Name:GANTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:1243 CALLE SANTIAGO
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6813
Mailing Address - Country:US
Mailing Address - Phone:805-219-9260
Mailing Address - Fax:
Practice Address - Street 1:892 27TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1444
Practice Address - Country:US
Practice Address - Phone:619-575-4687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150287164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse