Provider Demographics
NPI:1396390142
Name:FELICIANO, KRISTINE S
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:S
Last Name:FELICIANO
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 1:655 HARMON LOOP RD STE 108
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-6544
Mailing Address - Country:US
Mailing Address - Phone:671-633-3684
Mailing Address - Fax:671-633-3680
Practice Address - Street 1:525 CHALAN RAMON HAYA
Practice Address - Street 2:
Practice Address - City:YIGO
Practice Address - State:GU
Practice Address - Zip Code:96929
Practice Address - Country:US
Practice Address - Phone:671-653-9512
Practice Address - Fax:671-653-9515
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPH0191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist