Provider Demographics
NPI:1821053075
Name:HUCKLEBERRY, KRISTIN (ARNP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:HUCKLEBERRY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-272-5100
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:210 E GRAY ST STE 1105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3907
Practice Address - Country:US
Practice Address - Phone:502-583-1697
Practice Address - Fax:502-583-2120
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3247P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY950POtherSIHO
KY000000541708OtherANTHEM
KY1202794OtherCHA
KYP00293222OtherMEDICARE RAILROAD - KY
KY1202794OtherCHA
KY1361968Medicare PIN