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General NPI Number Information
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NPI Number | 1538633219
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Entity Type | Individual
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Provider Name | JAMIE KROESCH LIDSTER
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Gender | Female
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Dates
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Enumeration Date | 01/16/2019
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Last Update Date | 12/13/2024
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Provider Practice Location Address
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Address Line | 2210 ENCINITAS BLVD STE N
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City | ENCINITAS
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State | CA
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Zip | 92024-4376
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Country | US
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Telephone | 760-230-1888
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Fax |
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Provider Business Mailing Address
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Address Line | 3213 AVENIDA HACIENDA
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City | ESCONDIDO
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State | CA
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Zip | 92029-7927
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Country | US
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Telephone | 760-533-2739
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95006076
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License Number State | CA
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