MEDICARE: KRISTINE COLVIN FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71005889A	IN

General Provider Information

NPI Number	:	1154790137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE COLVIN FNP-C

Provider Business Mailing Address
First Line	:	104 CONNIE AVE
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-2305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 CONNIE AVE
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-2305
Country	:	US
Telephone Number	:	812-883-2696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2015
Last Update Date	:	06/16/2022

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