Healthcare Provider Details

I. General information

NPI: 1649994963
Provider Name (Legal Business Name): KRISTINA LEE MOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 E IMPERIAL HWY
LYNWOOD CA
90262-2609
US

IV. Provider business mailing address

3630 E IMPERIAL HWY
LYNWOOD CA
90262-2609
US

V. Phone/Fax

Practice location:
  • Phone: 310-900-4525
  • Fax:
Mailing address:
  • Phone: 310-900-4525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: