Basic Information
Provider Information
NPI: 1003004144
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MICHAEL
FirstName: KRISTELL
MiddleName: LYNN
NamePrefix: MRS.
NameSuffix:  
Credential: CFNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 300 TWINING ST
Address2: BLDG 760
City: MAXWELL AFB
State: AL
PostalCode: 361126027
CountryCode: US
TelephoneNumber: 3349535565
FaxNumber: 3349538607
Practice Location
Address1: 300 TWINING ST
Address2: BLDG 760
City: MAXWELL AFB
State: AL
PostalCode: 361126027
CountryCode: US
TelephoneNumber: 3349535565
FaxNumber: 3349538607
Other Information
ProviderEnumerationDate: 10/12/2007
LastUpdateDate: 07/07/2016
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.


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