Provider Demographics
NPI:1467715094
Name:HIGGINBOTHAM, KRISTAN L
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:L
Last Name:HIGGINBOTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N WABASH AVE STE G-20
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2605
Mailing Address - Country:US
Mailing Address - Phone:765-660-7616
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1391 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1913
Practice Address - Country:US
Practice Address - Phone:765-660-7900
Practice Address - Fax:765-671-7751
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28159335A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000779644OtherANTHEM
IN201079220Medicaid
INM400075406Medicare PIN