Provider Demographics
NPI:1831812676
Name:MBAMALU, KRISTINE (DNP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:MBAMALU
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20515 W WISTERIA CT
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4989
Mailing Address - Country:US
Mailing Address - Phone:310-531-6645
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH ST STE 280
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4305
Practice Address - Country:US
Practice Address - Phone:310-515-8113
Practice Address - Fax:310-538-2102
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95205873163W00000X
CA95022736363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse