MEDICARE: KRISTIAN ALLEN INGEBRETSEN RN, SRNA

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1891402814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIAN ALLEN INGEBRETSEN RN, SRNA

Provider Business Mailing Address
First Line	:	1136 N AMERICAN ST UNIT 404
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-1680
Country	:	US
Telephone Number	:	206-794-5902
Fax Number	:

Provider Business Practice Location Address
First Line	:	1136 N AMERICAN ST UNIT 404
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-1680
Country	:	US
Telephone Number	:	206-794-5902
Fax Number	:

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

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	11/04/2022

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