Healthcare Provider Details

I. General information

NPI: 1154947851
Provider Name (Legal Business Name): KRISTIAN NOELLE BASTRESS DNP, APNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIAN NOELLE JOHANNES

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 S KOELLER ST
OSHKOSH WI
54902-6186
US

IV. Provider business mailing address

N9052 LILAC RD
MENASHA WI
54952-8115
US

V. Phone/Fax

Practice location:
  • Phone: 920-223-7100
  • Fax:
Mailing address:
  • Phone: 920-379-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10195-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: