Provider Demographics
NPI:1720527674
Name:BAGLEY, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BAGLEY
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 1:2340 KNOB CREEK RD
Mailing Address - Street 2:STE 720
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2977
Mailing Address - Country:US
Mailing Address - Phone:423-232-6120
Mailing Address - Fax:423-232-6125
Practice Address - Street 1:101 MEDTECH PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-232-6120
Practice Address - Fax:423-232-6125
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner