Provider Demographics
NPI:1144093477
Name:KINGSMORE, KOURTNEY MARIE
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:MARIE
Last Name:KINGSMORE
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 1:206 1/2 RUBY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92662-4802
Mailing Address - Country:US
Mailing Address - Phone:805-501-9277
Mailing Address - Fax:
Practice Address - Street 1:1000 CALLE AMANECER
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6214
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT3040512251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics