Provider Demographics
NPI:1801174313
Name:HARWICK, KRISTA LYNN (NP-C)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNN
Last Name:HARWICK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:LYNN
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:1522 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3652
Mailing Address - Country:US
Mailing Address - Phone:208-743-8416
Mailing Address - Fax:
Practice Address - Street 1:1522 17TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3652
Practice Address - Country:US
Practice Address - Phone:208-743-8416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1085A363LP2300X
WAAP 60282458363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8916681Medicare PIN