Healthcare Provider Details

I. General information

NPI: 1306707625
Provider Name (Legal Business Name): KRISTY HANTHORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 LANDMARK DR STE A
LAFAYETTE IN
47905-6652
US

IV. Provider business mailing address

29943 NETWORK PL
CHICAGO IL
60673-4790
US

V. Phone/Fax

Practice location:
  • Phone: 317-706-7246
  • Fax:
Mailing address:
  • Phone: 317-706-7246
  • Fax: 317-706-3417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71017440A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number71017440A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: