Provider Demographics
NPI:1467078261
Name:MOMENEE, KRISTEN A (NP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:MOMENEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9558
Mailing Address - Country:US
Mailing Address - Phone:260-385-3298
Mailing Address - Fax:
Practice Address - Street 1:7201 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2228
Practice Address - Country:US
Practice Address - Phone:260-432-1800
Practice Address - Fax:260-432-1804
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173707A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner