Provider Demographics
NPI:1972892313
Name:KISTNER, JENNIFER ELIZABETH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:KISTNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 NETWORK CENTRE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4632
Mailing Address - Country:US
Mailing Address - Phone:217-347-2707
Mailing Address - Fax:217-347-2827
Practice Address - Street 1:203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424
Practice Address - Country:US
Practice Address - Phone:217-925-5730
Practice Address - Fax:217-925-5736
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008758363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041359392OtherRN LICENSE
IL209008758OtherNURSE PRACTITIONER LICENSE