Provider Demographics
NPI:1679197982
Name:GANNETT, KRISTIN CORINNE (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:CORINNE
Last Name:GANNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1360 HILLCOURT ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6509
Mailing Address - Country:US
Mailing Address - Phone:541-301-0692
Mailing Address - Fax:
Practice Address - Street 1:691 MURPHY RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4311
Practice Address - Country:US
Practice Address - Phone:541-789-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202004201NP363LF0000X
OR202004201NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily