Healthcare Provider Details

I. General information

NPI: 1871422824
Provider Name (Legal Business Name): KIMBERLY G BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20684 IRIS CANYON RD
RIVERSIDE CA
92508-3525
US

IV. Provider business mailing address

20684 IRIS CANYON RD
RIVERSIDE CA
92508-3525
US

V. Phone/Fax

Practice location:
  • Phone: 951-538-0813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95052393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: