Healthcare Provider Details

I. General information

NPI: 1144331000
Provider Name (Legal Business Name): KIMBERLY STACIE HANSEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 PIPELINE AVE
CHINO CA
91710-4959
US

IV. Provider business mailing address

2712 S MONTEGO APT F
ONTARIO CA
91761-0438
US

V. Phone/Fax

Practice location:
  • Phone: 909-591-3902
  • Fax:
Mailing address:
  • Phone: 909-947-3731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: