Provider Demographics
NPI:1073514840
Name:HIMMERICK, KRISTINE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:HIMMERICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 FLOSDEN RD SPC 98
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-3924
Mailing Address - Country:US
Mailing Address - Phone:970-240-3395
Mailing Address - Fax:
Practice Address - Street 1:1141 PEAR TREE LN STE 100
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6485
Practice Address - Country:US
Practice Address - Phone:707-254-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61674257Medicaid
CO61674257Medicaid