Provider Demographics
NPI:1245876614
Name:DEARRUDA WHARTON, KRISTIN ELISABETH (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELISABETH
Last Name:DEARRUDA WHARTON
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ELISABETH
Other - Last Name:DEARRUDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:513 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-3017
Mailing Address - Country:US
Mailing Address - Phone:183-872-3302
Mailing Address - Fax:
Practice Address - Street 1:513 5TH AVE W
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-3017
Practice Address - Country:US
Practice Address - Phone:183-872-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7075363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7075OtherMINNESOTA BOARD OF NURSING- APRN LICENSE
11185596OtherINTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS
MN16274OtherMINNESOTA BOARD OF NURSING- PUBLIC HEALTH NURSE
MN169220-0OtherMINNESOTA BOARD OF NURSING
F09191840OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS