Provider Demographics
NPI:1871828301
Name:BRANTLEY, KIM Y (CLC)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:Y
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32256 VIA ARIAS
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3873
Mailing Address - Country:US
Mailing Address - Phone:951-373-3080
Mailing Address - Fax:
Practice Address - Street 1:32256 VIA ARIAS
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-3873
Practice Address - Country:US
Practice Address - Phone:951-373-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAALPP-211253174N00000X
CA6243374J00000X
CA88040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA88040OtherMASSAGE THERAPY