Provider Demographics
NPI:1912257346
Name:NISSEN, KIMBERLY S (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:NISSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 881304
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92168-1304
Mailing Address - Country:US
Mailing Address - Phone:619-886-5057
Mailing Address - Fax:760-458-4428
Practice Address - Street 1:2815 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3815
Practice Address - Country:US
Practice Address - Phone:619-886-5057
Practice Address - Fax:760-458-4428
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN532252163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy