Provider Demographics
NPI:1083163505
Name:MAIN, KRISTEN LYNN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNN
Last Name:MAIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 PHOENIX VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4281
Mailing Address - Country:US
Mailing Address - Phone:636-561-0871
Mailing Address - Fax:
Practice Address - Street 1:2121 BARRETT STATION RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1606
Practice Address - Country:US
Practice Address - Phone:314-394-1923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013313363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily