Provider Demographics
NPI:1023023728
Name:ELLSTROM, KATHLEEN ELOISE (PHD, RN, APRN,BC)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ELOISE
Last Name:ELLSTROM
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Gender:F
Credentials:PHD, RN, APRN,BC
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Mailing Address - Street 1:22595 CARDINAL ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5732
Mailing Address - Country:US
Mailing Address - Phone:909-783-0594
Mailing Address - Fax:909-783-6714
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:111P
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-583-6095
Practice Address - Fax:909-777-3214
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CA539364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical