Provider Demographics
NPI:1740695634
Name:MOTLEY, KRISTEN REINCKE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:REINCKE
Last Name:MOTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:REINCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS, PA-C
Mailing Address - Street 1:2401 E ST NW SA-1, SUITE L301
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0001
Mailing Address - Country:US
Mailing Address - Phone:202-663-1542
Mailing Address - Fax:
Practice Address - Street 1:4279 TIERRA REJADA RD
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3775
Practice Address - Country:US
Practice Address - Phone:805-222-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA200001887363A00000X
CT3497363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical