Provider Demographics
NPI:1114517406
Name:MCCOMIC, KRISTY RENEE (RN)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:RENEE
Last Name:MCCOMIC
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 3RD ST BLDG 285
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-5102
Mailing Address - Country:US
Mailing Address - Phone:337-531-3561
Mailing Address - Fax:337-531-3428
Practice Address - Street 1:1585 3RD STREET BUILDING 285
Practice Address - Street 2:ATTENTION: CREDENTIALS, ROOM 7064
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA070301163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management