Healthcare Provider Details

I. General information

NPI: 1720963804
Provider Name (Legal Business Name): KRISTINE SEVILLEJA GUMPAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 FIFT AVE
SAN DIEGO CA
92103-7859
US

IV. Provider business mailing address

763 CAMINITO ESTRELLA
CHULA VISTA CA
91910-7859
US

V. Phone/Fax

Practice location:
  • Phone: 858-832-2478
  • Fax:
Mailing address:
  • Phone: 619-888-1861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95342979
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number892401
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: