Healthcare Provider Details

I. General information

NPI: 1144714205
Provider Name (Legal Business Name): KRISTIN J BIETZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 6TH AVE
MITCHELL SD
57301-1920
US

IV. Provider business mailing address

PO BOX 3100
CARBONDALE IL
62902-3100
US

V. Phone/Fax

Practice location:
  • Phone: 605-292-6262
  • Fax:
Mailing address:
  • Phone: 618-529-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP001385
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: