Basic Information
| Provider Information | |||||||||
| NPI: | 1386224657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRIAN | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | LOURDES | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 E DAVIE ST APT 427 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276013050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862730405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3024 NEW BERN AVE STE 305 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193501700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2021 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | RTL21-0969 | NC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.