Provider Demographics
NPI:1760262059
Name:VIDAURRI, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:VIDAURRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:MENDIVIL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:35089 SUNFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:SQUAW VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93675-9510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4946 E YALE AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1571
Practice Address - Country:US
Practice Address - Phone:559-458-0210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program