Provider Demographics
NPI:1851914220
Name:DISTEFANO, KIMBERLY ANNIS (LAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNIS
Last Name:DISTEFANO
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 1:2180 GARNET AVE STE 1F
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3674
Mailing Address - Country:US
Mailing Address - Phone:858-652-1332
Mailing Address - Fax:
Practice Address - Street 1:2180 GARNET AVE STE 1F
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3674
Practice Address - Country:US
Practice Address - Phone:858-652-1332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18562171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist