Provider Demographics
NPI:1780810606
Name:KIELEY, KRISTEN WIKHOLM (MD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:WIKHOLM
Last Name:KIELEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MYRTLE
Other - Last Name:WIKHOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:590 LA TAPADERA LN
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9479
Mailing Address - Country:US
Mailing Address - Phone:805-260-6785
Mailing Address - Fax:
Practice Address - Street 1:1100 MONTEREY ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3102
Practice Address - Country:US
Practice Address - Phone:805-542-9700
Practice Address - Fax:805-542-0584
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251612085B0100X, 2085R0202X, 2085U0001X
CAA1308142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound