Provider Demographics
NPI:1700383742
Name:LADD, KRYSTLE NICOLE (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:KRYSTLE
Middle Name:NICOLE
Last Name:LADD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 QUAIL TRL
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ME
Mailing Address - Zip Code:04093-3219
Mailing Address - Country:US
Mailing Address - Phone:443-359-1706
Mailing Address - Fax:
Practice Address - Street 1:100 BRICKHILL AVE STE 304
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:443-359-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR190626363LP0808X
MDAC002377363LP0808X
MECNP181193363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health