Provider Demographics
NPI:1245542364
Name:CHAVEZ, KIMBERLY LEENIESE (SFIDC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEENIESE
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 CRAVEN ST
Mailing Address - Street 2:BRANCH MEDICAL CLINIC NAVAL STATION BLDG 3300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5599
Mailing Address - Country:US
Mailing Address - Phone:619-954-6168
Mailing Address - Fax:619-556-9419
Practice Address - Street 1:2450 CRAVEN ST
Practice Address - Street 2:BRANCH MEDICAL CLINIC NAVAL STATION BLDG 3300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5599
Practice Address - Country:US
Practice Address - Phone:619-954-6168
Practice Address - Fax:619-556-9419
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman