Basic Information
| Provider Information | |||||||||
| NPI: | 1336556380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S HANOVER AVE APT 5K | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405021879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457424844 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405367001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592571000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001275914 | VA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 612460 | NY | N | Nursing Service Providers | Registered Nurse | 367500000X | 0024175448 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 612460 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 3012083 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | K174864 | 01 | KY | MEDICARE | OTHER | 3012083 | 01 | KY | STATE LICENSE | OTHER | 7100539760 | 05 | KY | MEDICAID |