Provider Demographics
NPI:1700081726
Name:SHELTON, KRISTIE R (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:R
Last Name:SHELTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:R
Other - Last Name:WATHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-272-5754
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:411 E CHESTNUT ST # 4B5A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-2348
Practice Address - Fax:502-588-2334
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005151363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100023930Medicaid
IN200887030Medicaid
KY7100023930Medicaid
KYK056090Medicare PIN