Provider Demographics
NPI:1376179952
Name:JOHN, KIMBERLY NARGIS
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NARGIS
Last Name:JOHN
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 1:25558 MANDARIN CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3713
Mailing Address - Country:US
Mailing Address - Phone:909-969-0822
Mailing Address - Fax:
Practice Address - Street 1:25558 MANDARIN CT
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3713
Practice Address - Country:US
Practice Address - Phone:909-969-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486167163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty