Provider Demographics
NPI:1053821553
Name:MCCANN, KIMBERLY BROOKE (MSN, CPNP-PC, CNS)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:MCCANN
Suffix:
Gender:F
Credentials:MSN, CPNP-PC, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 BAGLEY AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-2931
Mailing Address - Country:US
Mailing Address - Phone:310-780-8723
Mailing Address - Fax:
Practice Address - Street 1:130 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BOULDER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95006-9432
Practice Address - Country:US
Practice Address - Phone:310-780-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4636364SP0200X
CA95007438363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics