Provider Demographics
NPI:1215953674
Name:DUPRE, KRISTIN MARIE (PA)
Entity type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:MARIE
Last Name:DUPRE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-5105
Mailing Address - Country:US
Mailing Address - Phone:813-754-1496
Mailing Address - Fax:813-754-2553
Practice Address - Street 1:802 W MLK BLVD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-5105
Practice Address - Country:US
Practice Address - Phone:813-754-1496
Practice Address - Fax:813-754-2553
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015733200Medicaid
FLND0LBOtherBLUE CROSS BLUE SHIELD