Provider Demographics
NPI:1982318978
Name:RICHARDSON, KATHLEEN LYNN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LYNN
Last Name:RICHARDSON
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:PO BOX 377417
Mailing Address - Street 2:
Mailing Address - City:OCEAN VIEW
Mailing Address - State:HI
Mailing Address - Zip Code:96737-7417
Mailing Address - Country:US
Mailing Address - Phone:808-854-4036
Mailing Address - Fax:
Practice Address - Street 1:790 E COLORADO BLVD FL 9
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2193
Practice Address - Country:US
Practice Address - Phone:626-354-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94027317390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program