Provider Demographics
NPI:1750392247
Name:MCNICOLL, KRYSTYNA (MD)
Entity type:Individual
Prefix:
First Name:KRYSTYNA
Middle Name:
Last Name:MCNICOLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 ALMA REAL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:881 ALMA REAL DR STE 101
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3792
Practice Address - Country:US
Practice Address - Phone:310-829-8923
Practice Address - Fax:424-212-5936
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A420840Medicaid
CA00A420840Medicaid
CAWA42084CMedicare PIN
CAWA42084AMedicare PIN