Healthcare Provider Details

I. General information

NPI: 1790273381
Provider Name (Legal Business Name): KRISTEN LAVELLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2018
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 TELEGRAPH AVE STE 2000
OAKLAND CA
94609-3239
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-8339
  • Fax:
Mailing address:
  • Phone: 510-204-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA166166
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: