Provider Demographics
NPI:1114233707
Name:SODER, KRISTEN MICHELLE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:SODER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MICHELLE
Other - Last Name:BURGDORFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 116638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-3207
Mailing Address - Country:US
Mailing Address - Phone:423-495-4819
Mailing Address - Fax:
Practice Address - Street 1:725 GLENWOOD DR STE E680
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1176
Practice Address - Country:US
Practice Address - Phone:423-495-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN143876163W00000X
TN15110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519729Medicaid