Basic Information
| Provider Information | |||||||||
| NPI: | 1861993701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODETT | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NURSE PRACTIONER | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 510 MED CT STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782583484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104944290 | ||||||||
| FaxNumber: | 2104944809 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 MED CT STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782583484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104944290 | ||||||||
| FaxNumber: | 2104944809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/28/2021 | ||||||||
| NPIReactivationDate: | 09/14/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 331535 | TX | N | Nursing Service Providers | Registered Nurse | Pediatrics | 207R00000X | 1052585 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.