Provider Demographics
NPI:1902148083
Name:PANGBORN, KRISTI CAROLYN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:CAROLYN
Last Name:PANGBORN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:KRISTI
Other - Middle Name:C
Other - Last Name:LINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:10790 RANCHO BERNARDO RD # 4S-205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-824-5004
Mailing Address - Fax:
Practice Address - Street 1:9898 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-824-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily