Basic Information
| Provider Information | |||||||||
| NPI: | 1003159450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSEY | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4017 STATE ROUTE 159 STE 101 | ||||||||
| Address2: | |||||||||
| City: | SMITHTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622852510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572875 | ||||||||
| FaxNumber: | 6182572895 | ||||||||
| Practice Location | |||||||||
| Address1: | 4017 STATE ROUTE 159 STE 101 | ||||||||
| Address2: | |||||||||
| City: | SMITHTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572875 | ||||||||
| FaxNumber: | 6182572895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2013 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 209010341 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | 209010341 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 209010341 | 01 | IL | IL LIC | OTHER |