Provider Demographics
NPI:1659020626
Name:HARVEY, KRISTINA NOELLE (PA-C, MPSAS, MSMS)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NOELLE
Last Name:HARVEY
Suffix:
Gender:F
Credentials:PA-C, MPSAS, MSMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3112
Mailing Address - Country:US
Mailing Address - Phone:309-655-3800
Mailing Address - Fax:
Practice Address - Street 1:420 NE GLEN OAK AVE STE 301
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3112
Practice Address - Country:US
Practice Address - Phone:309-655-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.009036363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical