Provider Demographics
NPI:1790147304
Name:HEXTALL, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:HEXTALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:2963 MARNE HWY
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2036
Practice Address - Country:US
Practice Address - Phone:856-638-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN603891163W00000X
NJ26NR17986800163W00000X
PASP015344363LF0000X
NJ26NJ00626300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse