Provider Demographics
NPI:1306110267
Name:VANDEVEER, KIM M (LAC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:VANDEVEER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:FRAUSTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:2 PADRE PKWY STE 302B
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2116
Mailing Address - Country:US
Mailing Address - Phone:510-918-8046
Mailing Address - Fax:
Practice Address - Street 1:2 PADRE PKWY STE 302B
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2116
Practice Address - Country:US
Practice Address - Phone:510-918-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14198171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist