Provider Demographics
NPI:1003469230
Name:DEROSA, KRISTEN M (NNP-BC, ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:DEROSA
Suffix:
Gender:F
Credentials:NNP-BC, ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DAMON RD
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-2622
Mailing Address - Country:US
Mailing Address - Phone:202-491-1043
Mailing Address - Fax:
Practice Address - Street 1:416 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1086
Practice Address - Country:US
Practice Address - Phone:508-756-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45177363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
104252227OtherNCC CERTIFICATION ID
104252227OtherNATIONAL CERTIFICATION CORPORATION: CERTIFICATION ID