Healthcare Provider Details

I. General information

NPI: 1588930317
Provider Name (Legal Business Name): KRISTINE NYQUIST FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

IV. Provider business mailing address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

V. Phone/Fax

Practice location:
  • Phone: 906-353-8666
  • Fax: 906-353-8799
Mailing address:
  • Phone: 906-353-8666
  • Fax: 906-353-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704257983
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: