Healthcare Provider Details

I. General information

NPI: 1881526309
Provider Name (Legal Business Name): KIMBERLY BLAKISTON RN, MSN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SAN LEANDRO BLVD
SAN LEANDRO CA
94577-1595
US

IV. Provider business mailing address

3424 MONTEREY BLVD
OAKLAND CA
94602-3564
US

V. Phone/Fax

Practice location:
  • Phone: 310-850-8856
  • Fax:
Mailing address:
  • Phone: 310-850-8856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number846221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: