Provider Demographics
NPI:1053440826
Name:THEETGE, KRISTIN MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
Last Name:THEETGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W LA VETA AVE STE 610
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4306
Mailing Address - Country:US
Mailing Address - Phone:714-285-2311
Mailing Address - Fax:714-285-2319
Practice Address - Street 1:1010 W LA VETA AVE STE 610
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4306
Practice Address - Country:US
Practice Address - Phone:714-285-2311
Practice Address - Fax:714-285-2319
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16619363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA639048OtherREGISTERED NURSE LICENSE