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General NPI Number Information
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NPI Number | 1184303356
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Entity Type | Individual
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Provider Name | KOURTNEY KATE VIDAL LVN
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Gender | Female
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Dates
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Enumeration Date | 07/14/2023
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Last Update Date | 07/14/2023
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Provider Practice Location Address
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Address Line | 7742 PASEO DEL REY APT 6
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City | PLAYA DEL REY
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State | CA
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Zip | 90293-8343
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Country | US
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Telephone | 562-552-7646
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 N SEPULVEDA BLVD # 605
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City | MANHATTAN BEACH
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State | CA
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Zip | 90266-5111
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Country | US
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Telephone | 424-542-1280
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | VN726574
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License Number State | CA
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