Provider Demographics
NPI:1639766470
Name:NAMBA, KIRSTYN
Entity Type:Individual
Prefix:
First Name:KIRSTYN
Middle Name:
Last Name:NAMBA
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 1:20702 EL TORO RD APT 417
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24361 EL TORO RD STE 140
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-8898
Practice Address - Country:US
Practice Address - Phone:949-540-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist