Provider Demographics
NPI:1972060150
Name:BRUFFETT, KRISTA (MA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:BRUFFETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:SORBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4600 BROADWAY STE 1300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1527
Mailing Address - Country:US
Mailing Address - Phone:916-874-9823
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1527
Practice Address - Country:US
Practice Address - Phone:916-874-9823
Practice Address - Fax:916-854-9614
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA900360172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR11521FOtherMEDI-CAL