=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144518630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN MARIE OLIVER CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2011
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 PLANTATION ISLAND DR S STE 202B
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32080-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-851-5121
-----------------------------------------------------
Fax | 407-851-0439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 PLANTATION ISLAND DR S STE 202B
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32080-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-851-5121
-----------------------------------------------------
Fax | 407-851-0439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 11025747
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------