Provider Demographics
NPI:1639839418
Name:TA, KIMBERLY
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 E GUASTI RD STE 315
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-1258
Mailing Address - Country:US
Mailing Address - Phone:909-942-5666
Mailing Address - Fax:909-435-4202
Practice Address - Street 1:3110 E GUASTI RD STE 315
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-1258
Practice Address - Country:US
Practice Address - Phone:909-942-5666
Practice Address - Fax:909-435-4202
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty