Healthcare Provider Details

I. General information

NPI: 1124886379
Provider Name (Legal Business Name): KIMBERLY NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MCHENRY VILLAGE WAY STE 11B
MODESTO CA
95350-4341
US

IV. Provider business mailing address

100 POPLAR AVE
MODESTO CA
95354-0510
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-5850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: