Provider Demographics
NPI:1245766799
Name:GARDNER, KIMBERLY ANN (BA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:MCMAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:3941 DE SABLA RD
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8604
Mailing Address - Country:US
Mailing Address - Phone:916-420-0512
Mailing Address - Fax:
Practice Address - Street 1:3941 DE SABLA RD
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8604
Practice Address - Country:US
Practice Address - Phone:916-420-0512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst