Provider Demographics
NPI:1346443066
Name:KIZZEE, CHRISTINA ETUK
Entity Type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:ETUK
Last Name:KIZZEE
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:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-0769
Mailing Address - Country:US
Mailing Address - Phone:281-530-6780
Mailing Address - Fax:281-530-8188
Practice Address - Street 1:11970 WILCREST DR STE 102
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77031-1923
Practice Address - Country:US
Practice Address - Phone:281-530-6780
Practice Address - Fax:281-530-8188
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX001007700320900000X
TX001007699320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001007886Medicaid
TX001007700Medicaid
TX001026121Medicaid