Basic Information
| Provider Information | |||||||||
| NPI: | 1326026733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | KRISTEL | ||||||||
| MiddleName: | MARLENA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1770 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 3202319141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 SE 6TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 3202319141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0807X | R-075272-7 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent | 364SP0809X | R-075272-7 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 99F41HA | 01 | BLUE CROSS | OTHER | 1012046 | 01 | PREFERRED ONE | OTHER | 8374115 | 01 | UBH | OTHER |