Provider Demographics
NPI:1215367180
Name:SOUTHERN, KRISTINE SHAW (LAC)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:SHAW
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:438 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2434
Mailing Address - Country:US
Mailing Address - Phone:831-423-3193
Mailing Address - Fax:831-459-8005
Practice Address - Street 1:115 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4424
Practice Address - Country:US
Practice Address - Phone:831-423-3193
Practice Address - Fax:831-459-8005
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15680171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist