Healthcare Provider Details

I. General information

NPI: 1609465830
Provider Name (Legal Business Name): KRISTIN JEAN RACOOSIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9999 FLYROD DR
PASO ROBLES CA
93446-7715
US

IV. Provider business mailing address

9999 FLYROD DR
PASO ROBLES CA
93446-7715
US

V. Phone/Fax

Practice location:
  • Phone: 626-664-4067
  • Fax:
Mailing address:
  • Phone: 626-664-4067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number348309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: