Healthcare Provider Details

I. General information

NPI: 1184482556
Provider Name (Legal Business Name): KIMBERLY ANNE ANGELES APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST STE 207
RIVERSIDE CA
92503-3948
US

IV. Provider business mailing address

3710 DEERLODGE CIR
CORONA CA
92881-8461
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-2092
  • Fax:
Mailing address:
  • Phone: 951-741-8478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95025476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: