Provider Demographics
NPI:1003159450
Name:MASSEY, KRISTEN NICOLE (APN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:MASSEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 STATE ROUTE 159 STE 101
Mailing Address - Street 2:
Mailing Address - City:SMITHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62285-2510
Mailing Address - Country:US
Mailing Address - Phone:618-257-2875
Mailing Address - Fax:618-257-2895
Practice Address - Street 1:4017 STATE ROUTE 159 STE 101
Practice Address - Street 2:
Practice Address - City:SMITHTON
Practice Address - State:IL
Practice Address - Zip Code:62285
Practice Address - Country:US
Practice Address - Phone:618-257-2875
Practice Address - Fax:618-257-2895
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010341363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010341OtherIL LIC