Basic Information
| Provider Information | |||||||||
| NPI: | 1699306795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILGORE | ||||||||
| FirstName: | KRISTIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94508 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871994508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 CALLE MEDICO STE 1 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757330003 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2020 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.