Provider Demographics
NPI: | 1952534323 |
---|---|
Name: | RICKERTSEN, KRISTEN ANN (APRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | KRISTEN |
Middle Name: | ANN |
Last Name: | RICKERTSEN |
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: | 213 EAST KIMBALL STREET |
Mailing Address - Street 2: | |
Mailing Address - City: | CALLAWAY |
Mailing Address - State: | NE |
Mailing Address - Zip Code: | 68825-2596 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 308-836-2294 |
Mailing Address - Fax: | 308-836-2451 |
Practice Address - Street 1: | 213 EAST KIMBALL STREET |
Practice Address - Street 2: | |
Practice Address - City: | CALLAWAY |
Practice Address - State: | NE |
Practice Address - Zip Code: | 68825-2596 |
Practice Address - Country: | US |
Practice Address - Phone: | 308-836-2294 |
Practice Address - Fax: | 308-836-2451 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-09-01 |
Last Update Date: | 2011-07-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NE | 111241 | 363L00000X |
OK | 96801 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OK | 200258850A | Medicaid |