Healthcare Provider Details

I. General information

NPI: 1457277204
Provider Name (Legal Business Name): KIMBERLY SHANTIL LULE CERVANTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 RANCHO CAMINO DR
POMONA CA
91766-7030
US

IV. Provider business mailing address

17092 TRUFA WAY
FONTANA CA
92336-3474
US

V. Phone/Fax

Practice location:
  • Phone: 410-910-1607
  • Fax:
Mailing address:
  • Phone: 909-229-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: