Provider Demographics
NPI:1669148565
Name:SCOTT, KIRSTEN LORRAINE (AGCNS-BC)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LORRAINE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 TOWNLINE RD NW
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49690-9651
Mailing Address - Country:US
Mailing Address - Phone:269-348-5880
Mailing Address - Fax:
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2386
Practice Address - Country:US
Practice Address - Phone:231-392-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318996364SE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency