Provider Demographics
NPI:1932467032
Name:GRACZYK, KRISTIN LEIGH TETZ (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEIGH TETZ
Last Name:GRACZYK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEIGH
Other - Last Name:TETZ-GRACZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2 DUNROVEN DR
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6739
Mailing Address - Country:US
Mailing Address - Phone:813-362-5964
Mailing Address - Fax:401-216-3854
Practice Address - Street 1:111 AUBURN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2103
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-216-3854
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP171084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGP256W-HILLSBOROUGHMedicare PIN