MEDICARE: KIMBERLY JOY VANYSSELDYK N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	469412	CA

General Provider Information

NPI Number	:	1376769208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY JOY VANYSSELDYK N.P.

Provider Business Mailing Address
First Line	:	1 MEDICAL PLAZA DR
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-3037
Country	:	US
Telephone Number	:	916-781-1697
Fax Number	:	916-781-5055

Provider Business Practice Location Address
First Line	:	1 MEDICAL PLAZA DR
Second Line	:	BREAST HEALTH CENTER
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-3037
Country	:	US
Telephone Number	:	916-781-1697
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	12/30/2015

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