Healthcare Provider Details

I. General information

NPI: 1053554931
Provider Name (Legal Business Name): KRISTIANA NOEL FARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

130 W VICTORIA ST
GARDENA CA
90248-3523
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax: 310-175-1592
Mailing address:
  • Phone: 310-715-2020
  • Fax: 310-175-1592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: