1245876614 NPI number — KRISTIN ELISABETH DEARRUDA WHARTON APRN, FNP-C

Table of content: KRISTIN ELISABETH DEARRUDA WHARTON APRN, FNP-C (NPI 1245876614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245876614 NPI number — KRISTIN ELISABETH DEARRUDA WHARTON APRN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEARRUDA WHARTON
Provider First Name:
KRISTIN
Provider Middle Name:
ELISABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEARRUDA
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
ELISABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, FNP-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1245876614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 E 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-2107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-249-5555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-249-5555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2019

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: 363LF0000X , with the licence number:  7075 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F09191840 . This is a "AMERICAN ACADEMY OF NURSE PRACTITIONERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11185596 . This is a "INTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7075 . This is a "MINNESOTA BOARD OF NURSING- APRN LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 16274 . This is a "MINNESOTA BOARD OF NURSING- PUBLIC HEALTH NURSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 169220-0 . This is a "MINNESOTA BOARD OF NURSING" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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