Provider Demographics
NPI:1821735424
Name:STEVENS, KRISTINE (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:T
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, AGNP-C
Mailing Address - Street 1:12626 E 48TH DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-6593
Mailing Address - Country:US
Mailing Address - Phone:928-247-2275
Mailing Address - Fax:
Practice Address - Street 1:2946 S AVENUE B
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7704
Practice Address - Country:US
Practice Address - Phone:928-275-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ255977363L00000X, 363LA2200X, 363LG0600X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ159894Medicaid