Provider Demographics
NPI:1891152369
Name:GAMBOA, KATHY II
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GAMBOA
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9636 CAMINITO MACKLIN
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2961
Mailing Address - Country:US
Mailing Address - Phone:619-312-5023
Mailing Address - Fax:
Practice Address - Street 1:9636 CAMINITO MACKLIN
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040
Practice Address - Country:US
Practice Address - Phone:619-312-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA829929163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse