Provider Demographics
NPI:1649433707
Name:PHELPS, KRISTIN LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LYNN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LYNN
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:210 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1898
Mailing Address - Country:US
Mailing Address - Phone:641-236-2055
Mailing Address - Fax:641-236-2907
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-2055
Practice Address - Fax:641-236-2907
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA73096OtherWELLMARK BCBS
IA73096OtherWELLMARK BCBS