Provider Demographics
NPI:1598257347
Name:KLUSMAN, KRISTY LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LYNN
Last Name:KLUSMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:KRISTY
Other - Middle Name:LYNN
Other - Last Name:RAITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6054 WHEATLANDS
Mailing Address - Street 2:
Mailing Address - City:SCOTTS
Mailing Address - State:MI
Mailing Address - Zip Code:49088-7729
Mailing Address - Country:US
Mailing Address - Phone:269-808-6612
Mailing Address - Fax:
Practice Address - Street 1:524 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5306
Practice Address - Country:US
Practice Address - Phone:269-324-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224347163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse