Provider Demographics
NPI:1760434302
Name:FIORENTINO, KRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:FIORENTINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W STATE ST
Mailing Address - Street 2:ST. C
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6013
Mailing Address - Country:US
Mailing Address - Phone:208-994-8656
Mailing Address - Fax:888-972-4280
Practice Address - Street 1:223 W STATE ST
Practice Address - Street 2:ST. C
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6013
Practice Address - Country:US
Practice Address - Phone:208-994-8656
Practice Address - Fax:888-972-4280
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806862700Medicaid
ID806862700Medicaid
G06911Medicare UPIN