Provider Demographics
NPI:1699409995
Name:KISHBAUGH, KRISTEL
Entity Type:Individual
Prefix:
First Name:KRISTEL
Middle Name:
Last Name:KISHBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEL
Other - Middle Name:
Other - Last Name:KISHBAUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:PO BOX 1174
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:MT
Mailing Address - Zip Code:59632-1174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 EDGERTON ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632-7724
Practice Address - Country:US
Practice Address - Phone:406-438-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT196230363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health