Provider Demographics
NPI:1689646622
Name:KRISTIANSEN, KJELL O (CRNA)
Entity Type:Individual
Prefix:
First Name:KJELL
Middle Name:O
Last Name:KRISTIANSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3603
Mailing Address - Country:US
Mailing Address - Phone:812-949-3442
Mailing Address - Fax:812-949-3441
Practice Address - Street 1:520 W 1ST ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3603
Practice Address - Country:US
Practice Address - Phone:812-949-3442
Practice Address - Fax:812-949-3441
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY501A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74050113Medicaid
IN000000039503OtherIN BCBS
IN000000039503OtherIN BCBS