Basic Information
Provider Information
NPI: 1003004144
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MICHAEL
FirstName: KRISTELL
MiddleName: L
NamePrefix: MRS.
NameSuffix:  
Credential: APN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 377 MDG/SGHC 2050A SECOND STREET SE
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871175522
CountryCode: US
TelephoneNumber: 5058463562
FaxNumber: 3349538607
Practice Location
Address1: US AIR FORCE 377 MDG/SGHC 2050A SECOND STREET SE
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871176027
CountryCode: US
TelephoneNumber: 5058463562
FaxNumber: 3349538607
Other Information
ProviderEnumerationDate: 10/12/2007
LastUpdateDate: 08/09/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X558669TXY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


Home