Provider Demographics
NPI:1588284251
Name:TAKANG, KEMERICK
Entity type:Individual
Prefix:
First Name:KEMERICK
Middle Name:
Last Name:TAKANG
Suffix:
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 1:5493 STONEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8933
Mailing Address - Country:US
Mailing Address - Phone:310-946-5578
Mailing Address - Fax:
Practice Address - Street 1:5493 STONEVIEW RD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-8933
Practice Address - Country:US
Practice Address - Phone:310-946-5578
Practice Address - Fax:949-695-3678
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95123976163W00000X, 363LP0808X
CA95022830363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner