Basic Information
| Provider Information | |||||||||
| NPI: | 1235252636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1537 OLIVER AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921095322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614334132 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5005 TEXAS ST | ||||||||
| Address2: | STE 203 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921083721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196920727 | ||||||||
| FaxNumber: | 6196920785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.