Provider Demographics
NPI:1265940563
Name:KJOLHEDE, KRISTINE ELIZABETH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:KJOLHEDE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6804 PETERS PATH
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6668
Mailing Address - Country:US
Mailing Address - Phone:214-693-5117
Mailing Address - Fax:
Practice Address - Street 1:904 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3550
Practice Address - Country:US
Practice Address - Phone:817-335-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-21
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX849501163W00000X
TXAP136050363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse