Provider Demographics
NPI:1144584806
Name:KIDD, JEANETTE MONIQUE (FNP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MONIQUE
Last Name:KIDD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 N SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1427
Mailing Address - Country:US
Mailing Address - Phone:310-638-1100
Mailing Address - Fax:310-638-0008
Practice Address - Street 1:1112 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-1427
Practice Address - Country:US
Practice Address - Phone:310-638-1100
Practice Address - Fax:310-638-0008
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily