Provider Demographics
NPI:1457396962
Name:CARRELL, KERISTYN J (NP)
Entity Type:Individual
Prefix:
First Name:KERISTYN
Middle Name:J
Last Name:CARRELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KERISTYN
Other - Middle Name:JO
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1125 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-4021
Mailing Address - Country:US
Mailing Address - Phone:307-347-2449
Mailing Address - Fax:307-347-6187
Practice Address - Street 1:1125 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-4021
Practice Address - Country:US
Practice Address - Phone:307-347-2449
Practice Address - Fax:307-347-6187
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY20520.0819363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
W20847Medicare PIN
Q70868Medicare UPIN