Provider Demographics
NPI:1942963293
Name:MAINES, KRISTOFER JOHN (RN)
Entity Type:Individual
Prefix:MR
First Name:KRISTOFER
Middle Name:JOHN
Last Name:MAINES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 ELM PARK ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4504
Mailing Address - Country:US
Mailing Address - Phone:626-429-3881
Mailing Address - Fax:
Practice Address - Street 1:760 S PASADENA AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105
Practice Address - Country:US
Practice Address - Phone:626-397-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95123233163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health