Healthcare Provider Details

I. General information

NPI: 1912463589
Provider Name (Legal Business Name): KATHRYN ELIZABETH KIZZAR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12143 NAVAJO RD
APPLE VALLEY CA
92308-7250
US

IV. Provider business mailing address

625 W YALE ST
ONTARIO CA
91762-1918
US

V. Phone/Fax

Practice location:
  • Phone: 760-240-1144
  • Fax:
Mailing address:
  • Phone: 925-202-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95083620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: