Healthcare Provider Details

I. General information

NPI: 1720179278
Provider Name (Legal Business Name): VIRGINIA P KRISTL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 1/2 LOUISIANA ST
SAN DIEGO CA
92116-4166
US

IV. Provider business mailing address

4437 1/2 LOUISIANA ST
SAN DIEGO CA
92116-4166
US

V. Phone/Fax

Practice location:
  • Phone: 207-632-7764
  • Fax:
Mailing address:
  • Phone: 207-632-7764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPF23095
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR050412
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number058363-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: