Provider Demographics
NPI:1568040434
Name:GRAHAM, KRISTINA (NBC-HWC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NBC-HWC
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 151546
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92175-1546
Mailing Address - Country:US
Mailing Address - Phone:619-244-7795
Mailing Address - Fax:
Practice Address - Street 1:4520 EXECUTIVE DR STE 111
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3019
Practice Address - Country:US
Practice Address - Phone:858-657-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-3091223