Provider Demographics
NPI:1750610044
Name:KNOBLOCH, KRISTIN NICOLE (APRN-CNS)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:KNOBLOCH
Suffix:
Gender:F
Credentials:APRN-CNS
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:BARBOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNS
Mailing Address - Street 1:3 PROFESSIONAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5011
Mailing Address - Country:US
Mailing Address - Phone:618-433-9300
Mailing Address - Fax:
Practice Address - Street 1:3 PROFESSIONAL DR STE C
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5011
Practice Address - Country:US
Practice Address - Phone:618-433-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK83379163W00000X, 364SC0200X
MO2012031746364SC0200X
IL277001352364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL277001352OtherAPRN