Provider Demographics
NPI:1821489220
Name:TATARKA, KRISTIN AMANDA (RN, FNP-BC, ACNS-BC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:AMANDA
Last Name:TATARKA
Suffix:
Gender:F
Credentials:RN, FNP-BC, ACNS-BC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:AMANDA
Other - Last Name:PONZANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2218 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6106
Mailing Address - Country:US
Mailing Address - Phone:330-392-5800
Mailing Address - Fax:
Practice Address - Street 1:8440 MARKET ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-6703
Practice Address - Country:US
Practice Address - Phone:330-965-9999
Practice Address - Fax:330-757-0000
Is Sole Proprietor?:No
Enumeration Date:2015-02-07
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA. 16690-NS364SA2200X
OHCOA. 17884-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0231015Medicaid