Basic Information
| Provider Information | |||||||||
| NPI: | 1023023728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLSTROM | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ELOISE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, RN, APRN,BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22595 CARDINAL ST | ||||||||
| Address2: | |||||||||
| City: | GRAND TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923135732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097830594 | ||||||||
| FaxNumber: | 9097836714 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | 111P | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095836095 | ||||||||
| FaxNumber: | 9097773214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SM0705X | 539 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical |
No ID Information.