Provider Demographics
NPI:1699415620
Name:NGUYEN, KATHLENE MANIMTIM
Entity Type:Individual
Prefix:
First Name:KATHLENE
Middle Name:MANIMTIM
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLENE
Other - Middle Name:VILLEGAS
Other - Last Name:MANIMTIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7159 MYRTLE PL
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5706
Mailing Address - Country:US
Mailing Address - Phone:619-415-9181
Mailing Address - Fax:
Practice Address - Street 1:7159 MYRTLE PL
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5706
Practice Address - Country:US
Practice Address - Phone:619-415-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020377363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner