Provider Demographics
NPI:1033646757
Name:NATHAN, KIRSTEN ALEXANDRA
Entity Type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:ALEXANDRA
Last Name:NATHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 SW CHAPMAN WAY UNIT 105
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-2461
Mailing Address - Country:US
Mailing Address - Phone:772-932-4014
Mailing Address - Fax:
Practice Address - Street 1:1700 S 23RD ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4803
Practice Address - Country:US
Practice Address - Phone:772-461-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1224207R00000X
FL16750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine