Basic Information
| Provider Information | |||||||||
| NPI: | 1619047271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICE | ||||||||
| FirstName: | NELLY | ||||||||
| MiddleName: | KIM | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZIMMERMAN | ||||||||
| OtherFirstName: | NELLI | ||||||||
| OtherMiddleName: | KIM | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PSC 819 | ||||||||
| Address2: | BOX 4581 | ||||||||
| City: | FPO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 09645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8808 BALBOA AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195328225 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 10/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44985 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 44985 | CO | N | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.