Healthcare Provider Details

I. General information

NPI: 1558914010
Provider Name (Legal Business Name): KRISTINA KOAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 N 63RD AVE
GLENDALE AZ
85308-7138
US

IV. Provider business mailing address

20402 N 15TH AVE
PHOENIX AZ
85027-3699
US

V. Phone/Fax

Practice location:
  • Phone: 623-376-4310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN157750
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: