Provider Demographics
NPI:1063503118
Name:NIELSEN-WINES, KATHRYN (DC)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:NIELSEN-WINES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 BEAUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-1833
Mailing Address - Country:US
Mailing Address - Phone:951-845-6456
Mailing Address - Fax:951-845-7485
Practice Address - Street 1:1074 BEAUMONT AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-1833
Practice Address - Country:US
Practice Address - Phone:951-845-6456
Practice Address - Fax:951-845-7485
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16014111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50215OtherAMERICAN SPECIALTY HEALTH
CADC0160140OtherBLUE SHIELD
CA4398450OtherAETNA
CADC0160140OtherANTHEM
CA4398450OtherAETNA