Provider Demographics
NPI:1801229778
Name:BRENNER, KIMBERLY ANN (LAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13172 NEPTUNE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3133
Mailing Address - Country:US
Mailing Address - Phone:510-667-9786
Mailing Address - Fax:
Practice Address - Street 1:2424 BLANDING AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1553
Practice Address - Country:US
Practice Address - Phone:510-415-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14569171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist