Provider Demographics
NPI:1588200042
Name:KOO, KRISTIN L (CNM)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:KOO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEE
Other - Last Name:KOO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE, FL 4
Practice Address - Street 2:YAWKEY BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-2000
Practice Address - Fax:617-414-5798
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR20043600163W00000X
NJ25ME00070100367A00000X
MARN2362061367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110185546AMedicaid