Provider Demographics
NPI:1407007164
Name:KIRK, KRISTIE LEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:LEE
Last Name:KIRK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9237
Mailing Address - Country:US
Mailing Address - Phone:574-825-5393
Mailing Address - Fax:574-534-7340
Practice Address - Street 1:984 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-9237
Practice Address - Country:US
Practice Address - Phone:574-825-5393
Practice Address - Fax:574-534-7340
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27059466A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse