Healthcare Provider Details

I. General information

NPI: 1205587698
Provider Name (Legal Business Name): KRISTIN FICKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GOLF COURSE RD # B
ST MARIES ID
83861-7190
US

IV. Provider business mailing address

130 GOLF COURSE RD # B
ST MARIES ID
83861-7190
US

V. Phone/Fax

Practice location:
  • Phone: 818-584-9323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: