Provider Demographics
NPI:1275072225
Name:YOUNGMAN, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:YOUNGMAN
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 1:427 HIGHWAY 49
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5666
Mailing Address - Country:US
Mailing Address - Phone:209-533-5065
Mailing Address - Fax:209-532-5445
Practice Address - Street 1:427 HIGHWAY 49
Practice Address - Street 2:SUITE 202
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5666
Practice Address - Country:US
Practice Address - Phone:209-533-5065
Practice Address - Fax:209-532-5445
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB719582OtherDRIVER'S LICENSE