Provider Demographics
NPI:1184353112
Name:KEITH, KRISTIE ANN
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:ANN
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 HARLAN WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-3310
Mailing Address - Country:US
Mailing Address - Phone:209-408-7229
Mailing Address - Fax:
Practice Address - Street 1:3221 HARLAN WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-3310
Practice Address - Country:US
Practice Address - Phone:209-408-7229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA181637164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse