Provider Demographics
NPI:1720179278
Name:KRISTL, VIRGINIA P (FNP)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:P
Last Name:KRISTL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4437 1/2 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4166
Mailing Address - Country:US
Mailing Address - Phone:207-632-7764
Mailing Address - Fax:
Practice Address - Street 1:4437 1/2 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4166
Practice Address - Country:US
Practice Address - Phone:207-632-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER050412363LF0000X
NH058363-23363LF0000X
CANPF23095363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
6013195OtherMVP
1720179278OtherANTHEM
NH30346582Medicaid
AA115100OtherHARVARD PILGRIM
7065043OtherCIGNA