Provider Demographics
NPI:1104544758
Name:TOMPKINS, KASANDRA TIFFANI
Entity type:Individual
Prefix:
First Name:KASANDRA
Middle Name:TIFFANI
Last Name:TOMPKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASANDRA
Other - Middle Name:TIFFANI
Other - Last Name:KETTGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 S EL DORADO ST STE 510
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2804
Mailing Address - Country:US
Mailing Address - Phone:209-623-1411
Mailing Address - Fax:209-478-1938
Practice Address - Street 1:6 S EL DORADO ST STE 510
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2804
Practice Address - Country:US
Practice Address - Phone:209-623-1411
Practice Address - Fax:209-478-1938
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator