Healthcare Provider Details

I. General information

NPI: 1548065162
Provider Name (Legal Business Name): TIERA KENNEDY-VARGAS RN,BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 04/28/2026
Certification Date: 02/17/2025
Deactivation Date: 03/12/2026
Reactivation Date: 04/28/2026

III. Provider practice location address

30650 RANCHO CALIFORNIA RD D406 #347
TEMECULA CA
92591
US

IV. Provider business mailing address

30650 RANCHO CALIFORNIA RD D406 #347
TEMECULA CA
92591
US

V. Phone/Fax

Practice location:
  • Phone: 925-351-2967
  • Fax:
Mailing address:
  • Phone: 925-200-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95082221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: