Healthcare Provider Details

I. General information

NPI: 1306222591
Provider Name (Legal Business Name): KRISTEN GAMM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE MLC 2010
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE MLC 2010
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4415
  • Fax: 513-636-7805
Mailing address:
  • Phone: 513-636-4415
  • Fax: 513-636-7805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN.305901-1
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCOA.17500-NP
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN.CNP.17500
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: