Provider Demographics
NPI:1184624751
Name:SIDELL, KRISTA K (NP)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:K
Last Name:SIDELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:M
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 601529
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1529
Mailing Address - Country:US
Mailing Address - Phone:704-384-7292
Mailing Address - Fax:704-384-8880
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-384-7292
Practice Address - Fax:704-384-8880
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900366363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005566Medicaid
NCNC7593AMedicare PIN
NC2807135BMedicare PIN
P74291Medicare UPIN
NC7005566Medicaid