Provider Demographics
NPI:1346018686
Name:PROVENCE, KRISTY (APRN, BSN, WCC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:APRN, BSN, WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15845 GARDNER WEST RD
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-9507
Mailing Address - Country:US
Mailing Address - Phone:913-207-5089
Mailing Address - Fax:
Practice Address - Street 1:15845 GARDNER WEST RD
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-9507
Practice Address - Country:US
Practice Address - Phone:913-207-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS116337163WW0000X
KS53-82741-021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty