Provider Demographics
NPI:1710025648
Name:LAVISTA, KIRSTEN (DN)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:
Last Name:LAVISTA
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 CERRILLOS RD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2612
Mailing Address - Country:US
Mailing Address - Phone:505-424-8990
Mailing Address - Fax:505-424-6377
Practice Address - Street 1:3600 CERRILLOS RD
Practice Address - Street 2:SUITE 407
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2612
Practice Address - Country:US
Practice Address - Phone:505-424-8990
Practice Address - Fax:505-424-6377
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0003174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist