Basic Information
| Provider Information | |||||||||
| NPI: | 1477683944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILLACKEY | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | CAROLYN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14261 BROWNING AVE APT 8 | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927806380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147308431 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21520 PIONEER BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | HAWAIIAN GARDENS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907162603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.