Provider Demographics
NPI:1477959724
Name:ERICKSON, KRISTEN C (NP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:C
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:C
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:819 BLOOMINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820
Mailing Address - Country:US
Mailing Address - Phone:217-356-1558
Mailing Address - Fax:217-356-8529
Practice Address - Street 1:819 BLOOMINGTON ROAD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:217-356-8529
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-011627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily