Healthcare Provider Details

I. General information

NPI: 1225021934
Provider Name (Legal Business Name): KRISTIE K MARBUT ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 BRIDGEPORT WAY W SUITE F
UNIVERSITY PLACE WA
98466-4325
US

IV. Provider business mailing address

3698 REDMAPLE RD
SALT LAKE CITY UT
84106-1521
US

V. Phone/Fax

Practice location:
  • Phone: 253-565-7686
  • Fax: 253-566-0210
Mailing address:
  • Phone: 801-906-0513
  • Fax: 801-906-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAP30004331
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number50963944405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP30004331
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: