Provider Demographics
NPI:1154040111
Name:MIKELL, KRISTINA (AGNP-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:MIKELL
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17855 DALLAS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6857
Mailing Address - Country:US
Mailing Address - Phone:909-295-6006
Mailing Address - Fax:909-331-4811
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1300
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4654
Practice Address - Country:US
Practice Address - Phone:855-434-7767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9502017363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology