Healthcare Provider Details

I. General information

NPI: 1174532196
Provider Name (Legal Business Name): PAUL HENRY LARDIZABAL KILEY R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

4TH & INTERLOOP RD WEED ARMY COMMUNITY HOSPITAL
FORT IRWIN CA
92310-5109
US

IV. Provider business mailing address

16950 JASMINE ST APT 134
VICTORVILLE CA
92395-5711
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-3144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-107938
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: