Provider Demographics
NPI:1932336278
Name:LUSBY, KRISTELLE
Entity Type:Individual
Prefix:
First Name:KRISTELLE
Middle Name:
Last Name:LUSBY
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 1:6399 SAN IGNACIO AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1215
Mailing Address - Country:US
Mailing Address - Phone:408-369-5620
Mailing Address - Fax:
Practice Address - Street 1:333 CITY BLVD W
Practice Address - Street 2:#705
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2903
Practice Address - Country:US
Practice Address - Phone:714-456-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-13
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107784208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery