Provider Demographics
NPI:1366640658
Name:ERICSSON, KRISTINA RENEE (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:RENEE
Last Name:ERICSSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NEW WAVERLY PL STE 310
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7404
Mailing Address - Country:US
Mailing Address - Phone:919-694-0025
Mailing Address - Fax:919-678-6901
Practice Address - Street 1:600 NEW WAVERLY PL STE 310
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518
Practice Address - Country:US
Practice Address - Phone:919-694-0025
Practice Address - Fax:919-678-6901
Is Sole Proprietor?:No
Enumeration Date:2007-07-07
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01844207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCU719BOtherMEDICARE PTAN
IL036127970Medicaid
NCNCU719BOtherMEDICARE PTAN