Healthcare Provider Details

I. General information

NPI: 1780810606
Provider Name (Legal Business Name): KRISTEN WIKHOLM KIELEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTEN MYRTLE WIKHOLM M.D.

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MONTEREY ST STE 200
SAN LUIS OBISPO CA
93401-3102
US

IV. Provider business mailing address

590 LA TAPADERA LN
NIPOMO CA
93444-9479
US

V. Phone/Fax

Practice location:
  • Phone: 805-542-9700
  • Fax: 805-542-0584
Mailing address:
  • Phone: 805-260-6785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number25161
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25161
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number25161
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA130814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: