Provider Demographics
NPI:1477905214
Name:MACK, KRISTEN ERIN (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ERIN
Last Name:MACK
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ERIN
Other - Last Name:SPEARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3117 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-785-9400
Mailing Address - Fax:479-755-6255
Practice Address - Street 1:3117 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-785-9400
Practice Address - Fax:479-755-6255
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR215150758Medicaid