Healthcare Provider Details

I. General information

NPI: 1477683944
Provider Name (Legal Business Name): MRS. KRISTEN CAROLYN KILLACKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21520 PIONEER BLVD STE 110
HAWAIIAN GARDENS CA
90716-2603
US

IV. Provider business mailing address

14261 BROWNING AVE APT 8
TUSTIN CA
92780-6380
US

V. Phone/Fax

Practice location:
  • Phone: 562-865-3644
  • Fax:
Mailing address:
  • Phone: 714-730-8431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: