Provider Demographics
NPI:1972183069
Name:WADDELL, KRISTELLE NICOLE (PMHNP)
Entity Type:Individual
Prefix:
First Name:KRISTELLE
Middle Name:NICOLE
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:KRISTELLE
Other - Middle Name:NICOLE
Other - Last Name:FABULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:402 MUSCOVY CT
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-4227
Mailing Address - Country:US
Mailing Address - Phone:410-652-8555
Mailing Address - Fax:
Practice Address - Street 1:1200 E JOPPA RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-5810
Practice Address - Country:US
Practice Address - Phone:443-798-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR201059363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR201059OtherLICENSE NUMBER