Provider Demographics
NPI:1083853352
Name:LUSSIER, KRISTA A (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:A
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4452
Mailing Address - Country:US
Mailing Address - Phone:480-325-5869
Mailing Address - Fax:
Practice Address - Street 1:6015 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4452
Practice Address - Country:US
Practice Address - Phone:480-325-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3229363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00763100OtherRAILROAD MEDICARE
AZ433588Medicaid
AZZ130327Medicare PIN