Provider Demographics
NPI:1356807598
Name:KEVILLE, KATHRYN ARIEL (LAC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ARIEL
Last Name:KEVILLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 W SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-4164
Mailing Address - Country:US
Mailing Address - Phone:856-297-9084
Mailing Address - Fax:
Practice Address - Street 1:315 E COTATI AVE STE E
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-7801
Practice Address - Country:US
Practice Address - Phone:707-242-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17507171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist