Provider Demographics
NPI:1679038103
Name:KO, KATHERINE (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21233 CORRAL CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2031
Mailing Address - Country:US
Mailing Address - Phone:909-569-4954
Mailing Address - Fax:
Practice Address - Street 1:2705 S DIAMOND BAR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3557
Practice Address - Country:US
Practice Address - Phone:626-965-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily