Healthcare Provider Details

I. General information

NPI: 1740131192
Provider Name (Legal Business Name): KIMBERLY DAWN GRANADOS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N MAIN ST
LAKE ELSINORE CA
92530-4118
US

IV. Provider business mailing address

495 E RINCON ST STE 215
CORONA CA
92879-1378
US

V. Phone/Fax

Practice location:
  • Phone: 855-505-7467
  • Fax: 888-975-8926
Mailing address:
  • Phone: 951-523-0117
  • Fax: 951-394-0685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95038401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: