Healthcare Provider Details

I. General information

NPI: 1083797948
Provider Name (Legal Business Name): KRISTINA JACQUELYN ST.CLAIR D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 555191
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

139 DOUGLAS AVENUE
PORTSMOUTH VA
23707
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1213
  • Fax:
Mailing address:
  • Phone: 845-216-2401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number010220059
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0102202059
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: