Provider Demographics
NPI:1265886345
Name:LANK, KIMBERLY (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LANK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19582 BEACH BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5950
Mailing Address - Country:US
Mailing Address - Phone:714-477-8001
Mailing Address - Fax:
Practice Address - Street 1:19582 BEACH BLVD STE 360
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648
Practice Address - Country:US
Practice Address - Phone:714-477-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A15360208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KL3232267556OtherKL3232267556