Healthcare Provider Details

I. General information

NPI: 1932336278
Provider Name (Legal Business Name): KRISTELLE LUSBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2009
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CITY BLVD W #705
ORANGE CA
92868-2903
US

IV. Provider business mailing address

6399 SAN IGNACIO AVE STE 120
SAN JOSE CA
95119-1215
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5532
  • Fax:
Mailing address:
  • Phone: 408-369-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA107784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: