Provider Demographics
NPI:1194468900
Name:HARGIS, KRISTEN RENA
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RENA
Last Name:HARGIS
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 1:369 MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1008
Mailing Address - Country:US
Mailing Address - Phone:859-310-0791
Mailing Address - Fax:
Practice Address - Street 1:369 MULBERRY DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1008
Practice Address - Country:US
Practice Address - Phone:859-310-0791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0024374041Medicaid