MEDICARE: DR. KRISTY LYNN TOLLY M.D.

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	208000000X	Pediatrics Physician	A67500	CA

General Provider Information

NPI Number	:	1578591426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTY LYNN TOLLY M.D.

Provider Business Mailing Address
First Line	:	17822 BEACH BLVD
Second Line	:	SUITE 278
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7101
Country	:	US
Telephone Number	:	714-842-1441
Fax Number	:	714-843-0394

Provider Business Practice Location Address
First Line	:	17822 BEACH BLVD
Second Line	:	SUITE 278
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7101
Country	:	US
Telephone Number	:	714-842-1441
Fax Number	:	714-843-0394

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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