Provider Demographics
NPI:1306326699
Name:RICKARD, KRISTEN ANDREE (LVN)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANDREE
Last Name:RICKARD
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 PARADISE TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2502
Mailing Address - Country:US
Mailing Address - Phone:619-850-8282
Mailing Address - Fax:
Practice Address - Street 1:1153 PARADISE TRAIL RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-2502
Practice Address - Country:US
Practice Address - Phone:619-850-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X
CA690381164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone