Healthcare Provider Details

I. General information

NPI: 1407626294
Provider Name (Legal Business Name): CAROLINE KIMAIYO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BROCKTON AVE
RIVERSIDE CA
92506-1862
US

IV. Provider business mailing address

13135 HEACOCK ST APT 120
MORENO VALLEY CA
92553-2803
US

V. Phone/Fax

Practice location:
  • Phone: 951-275-8400
  • Fax:
Mailing address:
  • Phone: 714-809-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95027261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: