1710045778 NPI number — MARTA LEE KRISSOVICH ANP-BC, CWOCN-AP

Table of content: MARTA LEE KRISSOVICH ANP-BC, CWOCN-AP (NPI 1710045778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710045778 NPI number — MARTA LEE KRISSOVICH ANP-BC, CWOCN-AP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRISSOVICH
Provider First Name:
MARTA
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP-BC, CWOCN-AP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PATMAS
Provider Other First Name:
MARTA
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, MSN, CCCN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710045778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SUNSET BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT TOWNSEND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98368-8913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-316-6306
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 SUNSET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT TOWNSEND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98368-8913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-316-6306
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  N260535011 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WG0600X , with the licence number: RN60533319 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: N260535011 . This is a "ADVANCED REGISTERED NURSE PRACTITIONER LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2005458420 . This is a "CERTIFIED FOOT CARE NURSE (CFCN) BY WOCNCB" identifier . This identifiers is of the category "OTHER".
  • Identifier: RN60533319 . This is a "REGISTERED NURSE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2013652089 . This is a "CERTIFIED WOUND, OSTOMY & CONTINENCE CARE NURSE-ADV. PRACTICE (CWOCN-AP), WOCNCB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2011014922 . This is a "CERTIFIED GERONTOLOGICAL NURSE (RN-BC), ANCC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2008007311 . This is a "ADULT NURSE PRACTITIONER-BOARD CERTIFIED (ANP-BC) BY ANCC" identifier . This identifiers is of the category "OTHER".




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