Provider Demographics
NPI:1841533601
Name:KLIMCHOCK, LYDIA (RNP)
Entity type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:
Last Name:KLIMCHOCK
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:KOSTRUKOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNP, PAC
Mailing Address - Street 1:303 SAN GORGONIO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-3316
Mailing Address - Country:US
Mailing Address - Phone:619-225-9883
Mailing Address - Fax:
Practice Address - Street 1:303 SAN GORGONIO ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-3316
Practice Address - Country:US
Practice Address - Phone:619-225-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276394163WM0705X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA276394OtherRNP LICENSE NUMBER