Provider Demographics
NPI:1821442393
Name:KRELLWITZ, CHRISTA DANIELLE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTA
Middle Name:DANIELLE
Last Name:KRELLWITZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 ALTA AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2803
Mailing Address - Country:US
Mailing Address - Phone:909-985-1908
Mailing Address - Fax:
Practice Address - Street 1:1113 ALTA AVE STE 220
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-2803
Practice Address - Country:US
Practice Address - Phone:909-985-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004007261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFK5985140OtherDEA