Healthcare Provider Details

I. General information

NPI: 1104747989
Provider Name (Legal Business Name): KANDISE JAMERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15484 VANILLA BEAN LN
FONTANA CA
92336-3459
US

IV. Provider business mailing address

15484 VANILLA BEAN LN
FONTANA CA
92336-3459
US

V. Phone/Fax

Practice location:
  • Phone: 951-488-5034
  • Fax:
Mailing address:
  • Phone: 951-488-5034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: