Healthcare Provider Details

I. General information

NPI: 1356755847
Provider Name (Legal Business Name): KIMBERLY PUKAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12138 INDUSTRIAL BLVD #120
VICTORVILLE CA
92395-4757
US

IV. Provider business mailing address

11224 BRACEO ST
VICTORVILLE CA
92392-1960
US

V. Phone/Fax

Practice location:
  • Phone: 760-951-2599
  • Fax:
Mailing address:
  • Phone: 760-662-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number552871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: