Provider Demographics
NPI:1437770559
Name:LICKTEIG, KRISTI LEE (ARNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:LEE
Last Name:LICKTEIG
Suffix:
Gender:F
Credentials:ARNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 TIMBER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LANE
Mailing Address - State:KS
Mailing Address - Zip Code:66042-9350
Mailing Address - Country:US
Mailing Address - Phone:316-299-3570
Mailing Address - Fax:
Practice Address - Street 1:18975 NW 1600TH RD
Practice Address - Street 2:
Practice Address - City:GARNETT
Practice Address - State:KS
Practice Address - Zip Code:66032-8285
Practice Address - Country:US
Practice Address - Phone:316-299-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-110435163WP0808X
KS53-79644-092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health