Healthcare Provider Details

I. General information

NPI: 1619798808
Provider Name (Legal Business Name): KIMBERLY ANN BENTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ANN JARAMILLO

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16305 SAND CANYON AVE
IRVINE CA
92618-3782
US

IV. Provider business mailing address

202 CALLE SONORA
SAN CLEMENTE CA
92672-2208
US

V. Phone/Fax

Practice location:
  • Phone: 949-829-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95032465
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number95032465
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236494
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: