Provider Demographics
NPI:1659192375
Name:CARLSON, KRISS MARIE
Entity type:Individual
Prefix:
First Name:KRISS
Middle Name:MARIE
Last Name:CARLSON
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 1:919 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-2957
Mailing Address - Country:US
Mailing Address - Phone:818-256-2206
Mailing Address - Fax:
Practice Address - Street 1:919 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2957
Practice Address - Country:US
Practice Address - Phone:818-256-2206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4816201172V00000X
373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker