Provider Demographics
NPI:1669254892
Name:BANES-LECLAIR, KATHLEEN KIM (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:KIM
Last Name:BANES-LECLAIR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KAT
Other - Middle Name:
Other - Last Name:BANES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:4605 OLNEY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3668
Mailing Address - Country:US
Mailing Address - Phone:619-750-3447
Mailing Address - Fax:
Practice Address - Street 1:963 LANE AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3501
Practice Address - Country:US
Practice Address - Phone:615-693-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535791163WD1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal