Provider Demographics
NPI:1114505096
Name:MICHAELS, KRISTIN ETHEREDGE
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ETHEREDGE
Last Name:MICHAELS
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 1:78290 VIA PAVION
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4855
Mailing Address - Country:US
Mailing Address - Phone:808-214-2100
Mailing Address - Fax:
Practice Address - Street 1:78290 VIA PAVION
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4855
Practice Address - Country:US
Practice Address - Phone:808-214-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider