MEDICARE: KRISTINE GRACE DELA CRUZ VAN TASSEL FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95004410	CA

General Provider Information

NPI Number	:	1447609805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE GRACE DELA CRUZ VAN TASSEL FNP-C

Provider Business Mailing Address
First Line	:	8657 GOSSAMER WAY
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95624-3265
Country	:	US
Telephone Number	:	916-801-5221
Fax Number	:

Provider Business Practice Location Address
First Line	:	7811 LAGUNA BLVD STE 161
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7949
Country	:	US
Telephone Number	:	916-877-7778
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	09/28/2018

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