Basic Information
| Provider Information | |||||||||
| NPI: | 1740719210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDPARTNERS, ATTN: BARB COPELAND | ||||||||
| Address2: | 6920 POINTE INVERNESS WAY, SUITE 200 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 PROVIDENT DR STE A | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465803265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743712578 | ||||||||
| FaxNumber: | 5743712580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2017 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28216217A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IN | MEDICAID |