Provider Demographics
NPI:1477683944
Name:KILLACKEY, KRISTEN CAROLYN
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:CAROLYN
Last Name:KILLACKEY
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 1:14261 BROWNING AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6380
Mailing Address - Country:US
Mailing Address - Phone:714-730-8431
Mailing Address - Fax:
Practice Address - Street 1:21520 PIONEER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2603
Practice Address - Country:US
Practice Address - Phone:562-865-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management