Healthcare Provider Details

I. General information

NPI: 1851052633
Provider Name (Legal Business Name): CAROLYN KRETSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE KRETSCH

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 CURTIS ST APT D
BERKELEY CA
94702-2056
US

IV. Provider business mailing address

2441 CURTIS ST APT D
BERKELEY CA
94702-2056
US

V. Phone/Fax

Practice location:
  • Phone: 651-341-8863
  • Fax:
Mailing address:
  • Phone: 651-341-8863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019514
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95204483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: