Basic Information
| Provider Information | |||||||||
| NPI: | 1255839338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIENAST | ||||||||
| FirstName: | KRYSTINA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOEPP | ||||||||
| OtherFirstName: | KRYSTINA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 343 EVERGREEN LN | ||||||||
| Address2: | |||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530722403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627190519 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2018 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2017032701 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.