Provider Demographics
NPI:1366205007
Name:DAVIDSON, KRISTINA TARANGO (AGACNP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:TARANGO
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:TARANGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1111 E SPRUCE AVE STE 431
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3330
Mailing Address - Country:US
Mailing Address - Phone:559-450-7449
Mailing Address - Fax:
Practice Address - Street 1:1510 E HERNDON AVE STE 210
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3333
Practice Address - Country:US
Practice Address - Phone:559-450-7455
Practice Address - Fax:559-450-7473
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029458363L00000X
CA95041248163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner