Provider Demographics
NPI:1548398308
Name:MCDONALD, KORY LEANN (LPT)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:LEANN
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4834 ALTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2988
Mailing Address - Country:US
Mailing Address - Phone:909-573-6887
Mailing Address - Fax:
Practice Address - Street 1:508 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3012
Practice Address - Country:US
Practice Address - Phone:626-974-8122
Practice Address - Fax:626-974-8198
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31629167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician