Provider Demographics
NPI:1205079464
Name:REARDON, KRISTINA LEAH (CRNP)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:LEAH
Last Name:REARDON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7304
Mailing Address - Country:US
Mailing Address - Phone:817-250-4280
Mailing Address - Fax:
Practice Address - Street 1:800 5TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7304
Practice Address - Country:US
Practice Address - Phone:817-250-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN567319163W00000X
TX811965163W00000X, 363LA2200X
PASP009505363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX316409704Medicaid
TX316409704Medicaid