=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902612146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTAN R VALDES APRN - PMHNP - BC,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2024
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 MONTANA AVE STE J
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79925-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-249-6227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3802 KEYSTONE ST
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75041-5146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-790-6829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 1020722
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------