Provider Demographics
NPI:1225544711
Name:BROEKER AGRAVIADOR, KIMBERLY (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BROEKER AGRAVIADOR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 OCANA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1517
Mailing Address - Country:US
Mailing Address - Phone:562-715-7571
Mailing Address - Fax:
Practice Address - Street 1:5407 OCANA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-1517
Practice Address - Country:US
Practice Address - Phone:562-715-7571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA795096163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse