Provider Demographics
NPI:1154647634
Name:GLICK, KRISTINA K (RN)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:K
Last Name:GLICK
Suffix:
Gender:F
Credentials:RN
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Mailing Address - Street 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:317-576-1335
Mailing Address - Fax:317-343-6562
Practice Address - Street 1:3118 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3710
Practice Address - Country:US
Practice Address - Phone:765-864-4160
Practice Address - Fax:765-400-4467
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2023-01-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN28148252A163W00000X
IN71003254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200991290Medicaid
IN200991290Medicaid
INPENDINGOtherANTHEM PROVIDER NUMBER
INPENDINGMedicaid
INPENDINGMedicare PIN