Basic Information
| Provider Information | |||||||||
| NPI: | 1992027205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORMAN | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP-PC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | KRISTI | ||||||||
| OtherMiddleName: | TOMETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CPNP-PC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1120 15TH ST STE BI1056 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213813 | ||||||||
| FaxNumber: | 7067219286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067218623 | ||||||||
| FaxNumber: | 7067211459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2010 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | RN117548 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LP0200X | RN117548NP | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LN0005X | RN117548 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 01365575 | 01 | GA | AMERIGROUP | OTHER | 588940 | 01 | GA | WELLCARE | OTHER | 000814305C | 05 | GA | MEDICAID |