Provider Demographics
NPI:1083927073
Name:STORES, KRISTIN LEWIS (ARNP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEWIS
Last Name:STORES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MICHELE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 43667
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-398-3760
Mailing Address - Fax:904-338-0852
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD STE 103
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5469
Practice Address - Country:US
Practice Address - Phone:904-338-0855
Practice Address - Fax:904-338-0852
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9246928363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01070656OtherRR MEDICARE
FL002587400Medicaid
FLDL399YMedicare PIN