Provider Demographics
NPI:1205162583
Name:NUTT, KRYSTIN DANIELLE (NP-C)
Entity type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:DANIELLE
Last Name:NUTT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729-8001
Mailing Address - Country:US
Mailing Address - Phone:406-682-4223
Mailing Address - Fax:406-682-3874
Practice Address - Street 1:305 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729-8001
Practice Address - Country:US
Practice Address - Phone:406-682-6862
Practice Address - Fax:406-682-4756
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT126210363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00726312Medicaid
MS302I503659OtherMEDICARE PTAN