Healthcare Provider Details

I. General information

NPI: 1841700556
Provider Name (Legal Business Name): KRISTYN Q WUNDER FNP & AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2017
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S COLLEGE RD STE 201
LAFAYETTE LA
70503-3038
US

IV. Provider business mailing address

1101 S COLLEGE RD STE 201
LAFAYETTE LA
70503-3038
US

V. Phone/Fax

Practice location:
  • Phone: 337-264-7209
  • Fax:
Mailing address:
  • Phone: 337-264-7209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP09602
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP09602
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: