Provider Demographics
NPI:1144746140
Name:FLACK, KRISTEN E (AGNP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:E
Last Name:FLACK
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 CUSTOMER CARE WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5167
Mailing Address - Country:US
Mailing Address - Phone:209-384-6493
Mailing Address - Fax:
Practice Address - Street 1:1540 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-238-4800
Practice Address - Fax:209-238-4890
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95078988163W00000X
CANP95007308363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse