Healthcare Provider Details

I. General information

NPI: 1174079115
Provider Name (Legal Business Name): KRISTINE ERICKSEN-MILLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 BIRCH ST STE 100
NEWPORT BEACH CA
92660-1940
US

IV. Provider business mailing address

11921 CARMEL CREEK RD APT 129
SAN DIEGO CA
92130-2585
US

V. Phone/Fax

Practice location:
  • Phone: 310-245-6503
  • Fax:
Mailing address:
  • Phone: 310-245-6503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004881
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95004881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: