Provider Demographics
NPI:1528600277
Name:SOUTHERLAND, KRISTINA (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24135 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-9792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24135 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-9792
Practice Address - Country:US
Practice Address - Phone:815-549-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020105363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner