Healthcare Provider Details

I. General information

NPI: 1912257346
Provider Name (Legal Business Name): KIMBERLY S. NISSEN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 CAMINO DEL RIO S SUITE 115
SAN DIEGO CA
92108-3815
US

IV. Provider business mailing address

PO BOX 881304
SAN DIEGO CA
92168-1304
US

V. Phone/Fax

Practice location:
  • Phone: 619-886-5057
  • Fax: 760-458-4428
Mailing address:
  • Phone: 619-886-5057
  • Fax: 760-458-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN532252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: