Basic Information
| Provider Information | |||||||||
| NPI: | 1043433014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONRAD | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIZZ | ||||||||
| OtherFirstName: | KRISTIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9800 SHELBYVILLE RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402232992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298585 | ||||||||
| FaxNumber: | 8556567325 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 SENTRY PKWY E STE 200 | ||||||||
| Address2: | |||||||||
| City: | BLUE BELL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194222332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009991249 | ||||||||
| FaxNumber: | 8556567325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA051325 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.