Basic Information
| Provider Information | |||||||||
| NPI: | 1134182421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLTZ | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 SW GAGE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853503111 | ||||||||
| FaxNumber: | 7853504701 | ||||||||
| Practice Location | |||||||||
| Address1: | 3313B THRASHER RD | ||||||||
| Address2: | |||||||||
| City: | WHITE CLOUD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660944028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855853450 | ||||||||
| FaxNumber: | 7855953493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53-45497-031 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 161582 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 200306850B | 05 | KS | MEDICAID |