Provider Demographics
NPI:1225369820
Name:KNIFFEN, KRISTINA M (PN-14938)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:KNIFFEN
Suffix:
Gender:F
Credentials:PN-14938
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 MISSION RD
Mailing Address - Street 2:PO BOX 306
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-238-2400
Mailing Address - Fax:208-238-5462
Practice Address - Street 1:717 MISSION RD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0306
Practice Address - Country:US
Practice Address - Phone:208-238-2400
Practice Address - Fax:208-238-5462
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN-14938164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse