=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053848200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY MARSHMAN M.S., LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2017
-----------------------------------------------------
Last Update Date | 05/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1531 S NOVATO BLVD STE E
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-572-7478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1254 GREENWAY DR
-----------------------------------------------------
City | EL SOBRANTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94803-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 17531
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------