Basic Information
Provider Information | |||||||||
NPI: | 1679660567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVERSOLE | ||||||||
FirstName: | KRISTIN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STOBAUGH | ||||||||
OtherFirstName: | KRISTIN | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5220 BELFORT RD | ||||||||
Address2: | STE 130 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322566017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044463451 | ||||||||
FaxNumber: | 9044463013 | ||||||||
Practice Location | |||||||||
Address1: | 5220 BELFORT RD | ||||||||
Address2: | STE 130 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322566017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044463451 | ||||||||
FaxNumber: | 9044463013 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2006 | ||||||||
LastUpdateDate: | 04/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0000X | ARNP2649042 | FL | N |   | Nursing Service Providers | Registered Nurse | Wound Care | 207RC0000X | 2649042 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | ARNP 2649042 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2083P0011X | ARNP2649042 | FL | Y |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
ID | Type | State | Issuer | Description | 003127800 | 05 | FL |   | MEDICAID |