Provider Demographics
NPI:1124120548
Name:KRAVITZ, KIRSTEN LEIGH (MSN CPNP)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LEIGH
Last Name:KRAVITZ
Suffix:
Gender:F
Credentials:MSN CPNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEIGH
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2505 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6135
Mailing Address - Country:US
Mailing Address - Phone:501-327-6000
Mailing Address - Fax:501-450-7559
Practice Address - Street 1:2505 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6135
Practice Address - Country:US
Practice Address - Phone:501-327-6000
Practice Address - Fax:501-450-7559
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159169758Medicaid
ARQ61190Medicare UPIN
AR5Y640Medicare PIN