Provider Demographics
NPI:1215280037
Name:PROVENCHER, KRISTIN LEA HOOD (CPNP-PC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEA HOOD
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 691597
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32869-1597
Mailing Address - Country:US
Mailing Address - Phone:407-898-1210
Mailing Address - Fax:407-898-2909
Practice Address - Street 1:615 E PRINCETON ST
Practice Address - Street 2:SUITE 510
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1456
Practice Address - Country:US
Practice Address - Phone:407-898-1210
Practice Address - Fax:407-898-2909
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9265639363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007190500Medicaid
FLY0E9GOtherBCBS OF FL
FL007190500Medicaid