Provider Demographics
NPI:1750781316
Name:MICHAUD, KORYN KIESLING (FNP-C)
Entity type:Individual
Prefix:
First Name:KORYN
Middle Name:KIESLING
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-7963
Mailing Address - Fax:505-232-1627
Practice Address - Street 1:1329 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:757-737-3415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-01
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM53742363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1617165OtherUNKNOWN