Healthcare Provider Details

I. General information

NPI: 1699399139
Provider Name (Legal Business Name): KRISTIN KATHLEEN MCMAHON RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6337 GLIDDEN ST
SAN DIEGO CA
92111-6915
US

IV. Provider business mailing address

6337 GLIDDEN ST
SAN DIEGO CA
92111-6915
US

V. Phone/Fax

Practice location:
  • Phone: 310-480-0212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number681529
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number681529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: