Healthcare Provider Details

I. General information

NPI: 1700312972
Provider Name (Legal Business Name): KAYLEIGH KIRK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 CRAVEN ST # 3300
SAN DIEGO CA
92136-5599
US

IV. Provider business mailing address

2450 CRAVEN ST # 3300
SAN DIEGO CA
92136-5599
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-8101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101265320
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101265320
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: