Provider Demographics
NPI:1558784769
Name:SHOULDERS, KRISTEE CROFT (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTEE
Middle Name:CROFT
Last Name:SHOULDERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRISTEE
Other - Middle Name:LEANN
Other - Last Name:CROFT-SHOULDERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0347
Mailing Address - Country:US
Mailing Address - Phone:270-988-3298
Mailing Address - Fax:270-988-4642
Practice Address - Street 1:141 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078-8043
Practice Address - Country:US
Practice Address - Phone:270-988-3298
Practice Address - Fax:270-988-4642
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008503363LF0000X, 363L00000X
KY1079475163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100308220Medicaid
KYK125211Medicare PIN
KYK125210Medicare PIN