Healthcare Provider Details

I. General information

NPI: 1609959576
Provider Name (Legal Business Name): KRISTINE C MAKI N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E CHANNEL ST
STOCKTON CA
95202-2628
US

IV. Provider business mailing address

PO BOX 779
STOCKTON CA
95201-0779
US

V. Phone/Fax

Practice location:
  • Phone: 209-944-4700
  • Fax: 209-944-4795
Mailing address:
  • Phone: 209-373-2800
  • Fax: 209-373-2873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13619
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number603819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: