=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174532196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL HENRY LARDIZABAL KILEY R.N.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4TH & INTERLOOP RD WEED ARMY COMMUNITY HOSPITAL
-----------------------------------------------------
City | FORT IRWIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92310-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-380-3144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16950 JASMINE ST APT 134
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-5711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 1-107938
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------