Provider Demographics
NPI:1376855346
Name:PON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:PON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMT
Mailing Address - Street 1:75 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-2500
Mailing Address - Country:US
Mailing Address - Phone:650-219-3570
Mailing Address - Fax:
Practice Address - Street 1:75 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-2500
Practice Address - Country:US
Practice Address - Phone:650-219-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3076225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist