Healthcare Provider Details

I. General information

NPI: 1780981266
Provider Name (Legal Business Name): KRISTYN GRAY PELLECCHIA N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 ARBOR DR # 851
SAN DIEGO CA
92103-2007
US

IV. Provider business mailing address

4845 TULA CT.
SAN DIEGO CA
92122-1407
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-5895
  • Fax: 619-543-7013
Mailing address:
  • Phone: 858-472-3423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: