Provider Demographics
NPI:1033775572
Name:CHRISTIE, KALICIA
Entity Type:Individual
Prefix:
First Name:KALICIA
Middle Name:
Last Name:CHRISTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KALICIA
Other - Middle Name:
Other - Last Name:CHRISTIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:5107 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4801
Mailing Address - Country:US
Mailing Address - Phone:325-280-6938
Mailing Address - Fax:
Practice Address - Street 1:5107 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4801
Practice Address - Country:US
Practice Address - Phone:210-614-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141376363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000000000Medicaid