Healthcare Provider Details

I. General information

NPI: 1720157233
Provider Name (Legal Business Name): KRISTINE SUPPLE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 SAVIERS RD
OXNARD CA
93033-5314
US

IV. Provider business mailing address

2705 LOMA VISTA RD SUITE 205
VENTURA CA
93003-1581
US

V. Phone/Fax

Practice location:
  • Phone: 805-487-5588
  • Fax: 805-487-5589
Mailing address:
  • Phone: 805-667-2801
  • Fax: 805-641-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: