Healthcare Provider Details

I. General information

NPI: 1316719099
Provider Name (Legal Business Name): KATHLEEN RODRIGUEZ MAKEPEACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE
FONTANA CA
92335-4219
US

IV. Provider business mailing address

PO BOX 1028
LOMITA CA
90717-0280
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: