Provider Demographics
NPI:1689196255
Name:HALTOM, KRISTEN ASHLEY (RN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ASHLEY
Last Name:HALTOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ASHLEY
Other - Last Name:VANHANDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2979 ALLIED ST STE C
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5567
Mailing Address - Country:US
Mailing Address - Phone:920-337-6740
Mailing Address - Fax:
Practice Address - Street 1:2979 ALLIED ST SUITE C
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-337-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233644-30163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391498501Medicaid