Provider Demographics
NPI:1174362131
Name:PALLAS, KRISTA (RN)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:PALLAS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-5896
Mailing Address - Country:US
Mailing Address - Phone:248-953-9067
Mailing Address - Fax:
Practice Address - Street 1:1355 BOGUE ST
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6207
Practice Address - Country:US
Practice Address - Phone:517-355-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704357990163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse