Provider Demographics
NPI:1245255454
Name:STEVENS, KRISTIN BROOK (OB GYN, NP)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:BROOK
Last Name:STEVENS
Suffix:
Gender:F
Credentials:OB GYN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:404 N CAYUGA STREET
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4219
Mailing Address - Country:US
Mailing Address - Phone:607-277-0969
Mailing Address - Fax:607-277-3242
Practice Address - Street 1:404 N CAYUGA STREET
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4219
Practice Address - Country:US
Practice Address - Phone:607-277-0969
Practice Address - Fax:607-277-3242
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF360284-1363LX0001X
NY22 438468163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02781744Medicaid
NYAA1307OtherMEDICARE GROUP
NYAA1307OtherMEDICARE GROUP