Provider Demographics
NPI:1720522824
Name:KINGMAN, PAIGE ELISE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:ELISE
Last Name:KINGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:ELISE
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:160 GATEWAY DR
Mailing Address - Street 2:#110
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-3317
Mailing Address - Country:US
Mailing Address - Phone:916-434-1623
Mailing Address - Fax:916-434-1625
Practice Address - Street 1:160 GATEWAY DR
Practice Address - Street 2:#110
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-3317
Practice Address - Country:US
Practice Address - Phone:916-434-1623
Practice Address - Fax:916-434-1625
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily