Healthcare Provider Details

I. General information

NPI: 1437830577
Provider Name (Legal Business Name): NICOLETTE MARIE KINSBURSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2089 SAWGRASS CREEK LN
CORONA CA
92883-0623
US

IV. Provider business mailing address

2089 SAWGRASS CREEK LN
CORONA CA
92883-0623
US

V. Phone/Fax

Practice location:
  • Phone: 951-741-1499
  • Fax:
Mailing address:
  • Phone: 951-741-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95060996
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-305695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: