Provider Demographics
NPI:1285629428
Name:RICKELMAN, KRISTIN DIANE (NP)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:DIANE
Last Name:RICKELMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:RICKELMAN
Other - Last Name:RIOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2081 BRONZE STAR DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5423
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-661-1027
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA552017OtherRN
CANPF 17161OtherNURSE PRACTITIONER FURNISHING NUMBER CERTIFICATE
CANPF 17161OtherNURSE PRACTITIONER FURNISHING NUMBER CERTIFICATE
PAKR1436295OtherHIGHMARK
PA50038692OtherCAPITAL BLUE CROSS
CANPF 17161OtherNURSE PRACTITIONER FURNISHING NUMBER CERTIFICATE
PAKR1436295OtherHIGHMARK