Provider Demographics
NPI:1023551363
Name:MERICLE, KRISTA NANETTE (RN)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:NANETTE
Last Name:MERICLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 CAMINO DE VIDA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2267
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:877-651-0289
Practice Address - Street 1:117 CAMINO DE VIDA STE 300
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2267
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:877-651-0289
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMNM-73375163W00000X
NMCNP-73289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7582Medicaid