Provider Demographics
NPI:1841896396
Name:CHURCH, KINDEL GRACE (NP)
Entity type:Individual
Prefix:
First Name:KINDEL
Middle Name:GRACE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KINDEL
Other - Middle Name:GRACE
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10 GLICINA ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92694-1824
Mailing Address - Country:US
Mailing Address - Phone:949-306-0685
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-5967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016118363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care