Provider Demographics
NPI:1316355761
Name:VAN DER HAM, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VAN DER HAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17150 NEWHOPE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4250
Mailing Address - Country:US
Mailing Address - Phone:714-599-9091
Mailing Address - Fax:
Practice Address - Street 1:17150 NEWHOPE ST STE 201
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4250
Practice Address - Country:US
Practice Address - Phone:714-751-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247000000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information