Provider Demographics
NPI:1639926793
Name:PROPHET, KRISTEN A
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:PROPHET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HEIGHTS OF HILL ST
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-1048
Mailing Address - Country:US
Mailing Address - Phone:508-259-8737
Mailing Address - Fax:
Practice Address - Street 1:25 ORIOL DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1911
Practice Address - Country:US
Practice Address - Phone:508-259-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2264348363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care