Basic Information
| Provider Information | |||||||||
| NPI: | 1891288007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUSE | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLANTON | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1967 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308091967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069228274 | ||||||||
| FaxNumber: | 7069226695 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 MOUNT PLEASANT RD | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308248140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065951461 | ||||||||
| FaxNumber: | 7065979824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 010102 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 83698 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.