Healthcare Provider Details

I. General information

NPI: 1144554668
Provider Name (Legal Business Name): KIMBERLEY ANNE LEE-THORP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 AVENIDA DEL MAR STE 215
SAN CLEMENTE CA
92672-4001
US

IV. Provider business mailing address

205 CALLE CONCHITA
SAN CLEMENTE CA
92672-5404
US

V. Phone/Fax

Practice location:
  • Phone: 949-547-0716
  • Fax:
Mailing address:
  • Phone: 949-547-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number570332-09 (NAT'L)
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: