Provider Demographics
NPI:1003471079
Name:RUIZ, KRISTY ANNA
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:ANNA
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 E BRIER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2880
Mailing Address - Country:US
Mailing Address - Phone:909-501-0820
Mailing Address - Fax:
Practice Address - Street 1:658 E BRIER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-501-0820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA
CAH5318OtherCOUNTY OF SAN BERNARDINO