Basic Information
| Provider Information | |||||||||
| NPI: | 1750781316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAUD | ||||||||
| FirstName: | KORYN | ||||||||
| MiddleName: | KIESLING | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627963 | ||||||||
| FaxNumber: | 5052321627 | ||||||||
| Practice Location | |||||||||
| Address1: | 1329 GUSDORF RD | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577373415 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2014 | ||||||||
| LastUpdateDate: | 08/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 53742 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1617165 | 01 | CO | UNKNOWN | OTHER |