Provider Demographics
NPI:1740063676
Name:NELSON, KRISTA JOY
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:JOY
Last Name:NELSON
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 1:622 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3504
Mailing Address - Country:US
Mailing Address - Phone:316-680-0644
Mailing Address - Fax:
Practice Address - Street 1:622 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3504
Practice Address - Country:US
Practice Address - Phone:316-680-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03589106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist