Provider Demographics
NPI:1114610433
Name:GAMBONI, KATHLEEN RANAE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RANAE
Last Name:GAMBONI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1018
Mailing Address - Country:US
Mailing Address - Phone:805-792-2270
Mailing Address - Fax:
Practice Address - Street 1:784 HIGH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5243
Practice Address - Country:US
Practice Address - Phone:805-540-6500
Practice Address - Fax:805-540-6501
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator