Healthcare Provider Details

I. General information

NPI: 1982318978
Provider Name (Legal Business Name): KATHLEEN LYNN RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 E COLORADO BLVD FL 9
PASADENA CA
91101-2193
US

IV. Provider business mailing address

PO BOX 377417
OCEAN VIEW HI
96737-7417
US

V. Phone/Fax

Practice location:
  • Phone: 626-354-6440
  • Fax:
Mailing address:
  • Phone: 808-854-4036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number94027317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: