Healthcare Provider Details

I. General information

NPI: 1053440826
Provider Name (Legal Business Name): KRISTIN MARIE THEETGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE STE 610
ORANGE CA
92868-4306
US

IV. Provider business mailing address

1010 W LA VETA AVE STE 610
ORANGE CA
92868-4306
US

V. Phone/Fax

Practice location:
  • Phone: 714-285-2311
  • Fax: 714-285-2319
Mailing address:
  • Phone: 714-285-2311
  • Fax: 714-285-2319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number16619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: