Provider Demographics
NPI:1790187003
Name:ODDEN, KRISTA KAY (AGNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:KAY
Last Name:ODDEN
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:KAY
Other - Last Name:GAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4150 CLEMENT ST # 136
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1563
Mailing Address - Country:US
Mailing Address - Phone:347-439-5840
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:415-220-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA824700163W00000X
CA95001048363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse