1619133816 NPI number — MS. KRISTINA D GUTIERREZ PNP

Table of content: MS. KRISTINA D GUTIERREZ PNP (NPI 1619133816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619133816 NPI number — MS. KRISTINA D GUTIERREZ PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
KRISTINA
Provider Middle Name:
D
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619133816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2414 W 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78703-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-638-0688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17600 I-45
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-267-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  1917 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0222X , with the licence number: AP121416 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AP121416 . This is a "TX BOARD OF NURSING LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 384825 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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