Provider Demographics
NPI:1184192650
Name:BOETEL, KRISTINA R (CNP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:R
Last Name:BOETEL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4499
Mailing Address - Country:US
Mailing Address - Phone:605-886-8482
Mailing Address - Fax:605-884-4300
Practice Address - Street 1:506 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-4499
Practice Address - Country:US
Practice Address - Phone:605-886-8482
Practice Address - Fax:605-884-4300
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001496363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP001496OtherSTATE LICENSE