Basic Information
Provider Information | |||||||||
NPI: | 1952376923 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANCHE | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | WHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MINNICK-SMITH | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 852977309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4807820993 | ||||||||
FaxNumber: | 8553298939 | ||||||||
Practice Location | |||||||||
Address1: | 3530 S VAL VISTA DRIVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 852977309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4807820993 | ||||||||
FaxNumber: | 8553298939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 12/11/2013 | ||||||||
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 | 363L00000X | RN254159L | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LX0001X | RN145153 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
ID | Type | State | Issuer | Description | MM0938831 | 01 | AZ | DEA CERTIFICATE | OTHER | 549485 | 05 | AZ |   | MEDICAID |