Provider Demographics
NPI:1922160837
Name:KINGHAM, KERRY (MS)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:
Last Name:KINGHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 BLAKE WILBUR DRIVE, #2320
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305
Mailing Address - Country:US
Mailing Address - Phone:650-724-6702
Mailing Address - Fax:
Practice Address - Street 1:875 BLAKE WILBUR DR RM 2320
Practice Address - Street 2:STANFORD CANCER CENTER
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2205
Practice Address - Country:US
Practice Address - Phone:650-724-6702
Practice Address - Fax:650-498-5150
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGC000252OtherGENETIC COUNSELOR LICENSE NUMBER