Healthcare Provider Details

I. General information

NPI: 1891510756
Provider Name (Legal Business Name): KRISTA GUMP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 E COVINA BLVD
COVINA CA
91724-1523
US

IV. Provider business mailing address

704 GHENT ST
LA VERNE CA
91750-3829
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-5275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number503725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: