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
StateLicense IDTaxonomies
NE111241363L00000X
OK96801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200258850AMedicaid