Provider Demographics
NPI:1982334355
Name:FORS, KRISTIN ROSE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ROSE
Last Name:FORS
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 COMMONS DR W UNIT 5108
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8635
Mailing Address - Country:US
Mailing Address - Phone:770-722-6352
Mailing Address - Fax:
Practice Address - Street 1:4251 COMMONS DR W UNIT 5108
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8635
Practice Address - Country:US
Practice Address - Phone:770-722-6352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL-15532174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty