Provider Demographics
NPI:1972106847
Name:ETZCORN, KAITLIN (NP-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:ETZCORN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:BOESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10227 GREENMOOR DR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-2287
Mailing Address - Country:US
Mailing Address - Phone:260-602-7795
Mailing Address - Fax:
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28197283A163WX0800X
IN71011071A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic