Provider Demographics
NPI:1780981266
Name:PELLECCHIA, KRISTYN GRAY (NP)
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:GRAY
Last Name:PELLECCHIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 TULA CT.
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1407
Mailing Address - Country:US
Mailing Address - Phone:858-472-3423
Mailing Address - Fax:
Practice Address - Street 1:140 ARBOR DR # 851
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2007
Practice Address - Country:US
Practice Address - Phone:619-543-5895
Practice Address - Fax:619-543-7013
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21354363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner