Provider Demographics
NPI:1134172034
Name:DOMIER, KRISTINE K (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:K
Last Name:DOMIER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR138036-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN041H1DOOtherMNBS #
MN2003184OtherMEDICA #
MN49119OtherAMERICA'S PPO/ARAZ #
MN1134172034Medicaid
MN26506OtherNDBS #
MN49119OtherLHS #
MNHP42498OtherHEALTHPARTNERS #
MNDA9031016140OtherPREFERRED ONE #
MN49119OtherLHS #
MN430006213Medicare PIN