Healthcare Provider Details

I. General information

NPI: 1841533601
Provider Name (Legal Business Name): LYDIA KLIMCHOCK RNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYDIA KOSTRUKOFF RNP, PAC

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 03/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 SAN GORGONIO ST
SAN DIEGO CA
92106-3316
US

IV. Provider business mailing address

303 SAN GORGONIO ST
SAN DIEGO CA
92106-3316
US

V. Phone/Fax

Practice location:
  • Phone: 619-225-9883
  • Fax:
Mailing address:
  • Phone: 619-225-9883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number276394
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number276394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: