Provider Demographics
NPI:1710045778
Name:KRISSOVICH, MARTA LEE (ANP-BC, CWOCN-AP)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:LEE
Last Name:KRISSOVICH
Suffix:
Gender:F
Credentials:ANP-BC, CWOCN-AP
Other - Prefix:
Other - First Name:MARTA
Other - Middle Name:L
Other - Last Name:PATMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, CCCN
Mailing Address - Street 1:151 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-8913
Mailing Address - Country:US
Mailing Address - Phone:360-316-6306
Mailing Address - Fax:
Practice Address - Street 1:151 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-8913
Practice Address - Country:US
Practice Address - Phone:360-316-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAN260535011363LA2200X
WARN60533319163WG0600X
CA429364SG0600X
UT6293439-3102163W00000X
CA354939163W00000X
WAAP60546647363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAN260535011OtherADVANCED REGISTERED NURSE PRACTITIONER LICENSE
2005458420OtherCERTIFIED FOOT CARE NURSE (CFCN) BY WOCNCB
WARN60533319OtherREGISTERED NURSE LICENSE
2013652089OtherCERTIFIED WOUND, OSTOMY & CONTINENCE CARE NURSE-ADV. PRACTICE (CWOCN-AP), WOCNCB
2011014922OtherCERTIFIED GERONTOLOGICAL NURSE (RN-BC), ANCC
2008007311OtherADULT NURSE PRACTITIONER-BOARD CERTIFIED (ANP-BC) BY ANCC
2008007311OtherADULT NURSE PRACTITIONER-BOARD CERTIFIED (ANP-BC) BY ANCC
2013652089OtherCERTIFIED WOUND, OSTOMY & CONTINENCE CARE NURSE-ADV. PRACTICE (CWOCN-AP), WOCNCB