Healthcare Provider Details

I. General information

NPI: 1215850797
Provider Name (Legal Business Name): KRISTINA CREEK LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15082 N 59TH AVE APT 146
GLENDALE AZ
85306-5233
US

IV. Provider business mailing address

15082 N 59TH AVE APT 146
GLENDALE AZ
85306-5233
US

V. Phone/Fax

Practice location:
  • Phone: 602-583-2214
  • Fax:
Mailing address:
  • Phone: 602-583-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-24259
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: