Provider Demographics
NPI:1740679430
Name:VAN TASSELL, KRISTIN (FNP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5698
Mailing Address - Country:US
Mailing Address - Phone:801-477-9007
Mailing Address - Fax:
Practice Address - Street 1:118 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5698
Practice Address - Country:US
Practice Address - Phone:801-477-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-18
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6097293-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily