Provider Demographics
NPI:1477120582
Name:PRUSA, KRISTEN MICHELE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELE
Last Name:PRUSA
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MICHELE
Other - Last Name:TANKURSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16260 VENTURA BLVD STE LL15
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4931
Mailing Address - Country:US
Mailing Address - Phone:818-905-1567
Mailing Address - Fax:818-905-7406
Practice Address - Street 1:191 S BUENA VISTA ST STE 215
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4563
Practice Address - Country:US
Practice Address - Phone:818-906-4071
Practice Address - Fax:818-905-7406
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017466363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care