Provider Demographics
NPI:1043433014
Name:CONRAD, KRISTIE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:FIZZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9800 SHELBYVILLE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:502-429-8585
Mailing Address - Fax:855-656-7325
Practice Address - Street 1:470 SENTRY PKWY E STE 200
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2332
Practice Address - Country:US
Practice Address - Phone:800-999-1249
Practice Address - Fax:855-656-7325
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant