Provider Demographics
NPI:1184303356
Name:VIDAL, KOURTNEY KATE (LVN)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:KATE
Last Name:VIDAL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JAIRUS
Other - Middle Name:VIDAL
Other - Last Name:KLEEFISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:1601 N SEPULVEDA BLVD # 605
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5111
Mailing Address - Country:US
Mailing Address - Phone:424-542-1280
Mailing Address - Fax:
Practice Address - Street 1:7742 PASEO DEL REY APT 6
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-8343
Practice Address - Country:US
Practice Address - Phone:562-552-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN726574164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse