Provider Demographics
NPI:1447873971
Name:ARDELL, KATHLEEN B
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:ARDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:B
Other - Last Name:ARDELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3579 TAMMY CT
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2828
Mailing Address - Country:US
Mailing Address - Phone:209-386-2983
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3425
Practice Address - Country:US
Practice Address - Phone:619-481-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator