Basic Information
| Provider Information | |||||||||
| NPI: | 1437715208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANDYSIDE | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHRADER | ||||||||
| OtherFirstName: | KRISTY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
| FaxNumber: | 2086252070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 W PARK PL | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082152111 | ||||||||
| FaxNumber: | 8448073782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 61427 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 61427 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.