Provider Demographics
NPI:1003162579
Name:EDICK, KIMBERLY LEILANI (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LEILANI
Last Name:EDICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:LEILANI
Other - Last Name:PORTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:426 MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6640 ALTON PKWY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3734
Practice Address - Country:US
Practice Address - Phone:949-932-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA714375390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program