Healthcare Provider Details

I. General information

NPI: 1609470202
Provider Name (Legal Business Name): KIM PETRA BAILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2813 S MAIN ST
CORONA CA
92882-5942
US

IV. Provider business mailing address

4740 N GRAND AVE
COVINA CA
91724-2005
US

V. Phone/Fax

Practice location:
  • Phone: 951-273-0608
  • Fax:
Mailing address:
  • Phone: 626-859-2089
  • Fax: 626-859-6537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: