Provider Demographics
NPI:1699024992
Name:KING, KIERRA MARIE
Entity Type:Individual
Prefix:MS
First Name:KIERRA
Middle Name:MARIE
Last Name:KING
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 1:1621 VENICE BLVD APT#401
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291
Mailing Address - Country:US
Mailing Address - Phone:510-478-8834
Mailing Address - Fax:
Practice Address - Street 1:12510 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1338
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner