Provider Demographics
NPI:1821053075
Name:KOETTER, KRISTIN M (APRN)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:KOETTER
Suffix:
Gender:F
Credentials:APRN
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4123 DUTCHMANS LN STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4718
Practice Address - Country:US
Practice Address - Phone:502-899-6782
Practice Address - Fax:502-899-6783
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3247P363L00000X
IN71001123A363L00000X
KY3003247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY950POtherSIHO
KY000000541708OtherANTHEM
KY1202794OtherCHA
KYP00293222OtherMEDICARE RAILROAD - KY
KY1202794OtherCHA
KY1361968Medicare PIN