Provider Demographics
NPI:1679064190
Name:COLYER, KRISTINE D (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:D
Last Name:COLYER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:D
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 N WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1391 N BALDWIN AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2561
Practice Address - Country:US
Practice Address - Phone:765-660-7900
Practice Address - Fax:765-671-7751
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008143A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001191411OtherANTHEM
IN300017551Medicaid