Provider Demographics
NPI:1497477004
Name:KIKKERT, KRISTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KIKKERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:WALDKOETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1734 ELDERBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8260
Mailing Address - Country:US
Mailing Address - Phone:317-364-2562
Mailing Address - Fax:
Practice Address - Street 1:5521 W LINCOLN HWY STE 1A
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1098
Practice Address - Country:US
Practice Address - Phone:219-769-1362
Practice Address - Fax:219-769-8298
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical