Provider Demographics
NPI:1225384951
Name:MIKKELSEN, KRISTIN ANNA (CNP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNA
Last Name:MIKKELSEN
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:201 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-1037
Practice Address - Country:US
Practice Address - Phone:978-368-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2329461363L00000X, 363LP0808X
MECNP121069363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110150711AMedicaid
ME0028405Medicare PIN
MEE400204465Medicare PIN