Healthcare Provider Details

I. General information

NPI: 1760546113
Provider Name (Legal Business Name): KRISTINE PANIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 DWIGHT WAY STE 5
BERKELEY CA
94704-3503
US

IV. Provider business mailing address

2428 DWIGHT WAY STE 5
BERKELEY CA
94704-3503
US

V. Phone/Fax

Practice location:
  • Phone: 510-845-5155
  • Fax: 510-845-5155
Mailing address:
  • Phone: 510-845-5155
  • Fax: 510-845-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA54593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: