Provider Demographics
NPI:1053045195
Name:KNICKERBOCKER, KRISTINA NICOLE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICOLE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-4448
Mailing Address - Fax:614-293-3277
Practice Address - Street 1:300 W 10TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:614-293-4448
Practice Address - Fax:614-293-3277
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0031391363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496439Medicaid