Provider Demographics
NPI:1104287630
Name:MERSHON, KRISTINA KAY
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:KAY
Last Name:MERSHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:IL
Mailing Address - Zip Code:61006-9422
Mailing Address - Country:US
Mailing Address - Phone:815-761-7763
Mailing Address - Fax:
Practice Address - Street 1:2600 N BRINTON AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9532
Practice Address - Country:US
Practice Address - Phone:815-288-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily