Provider Demographics
NPI:1285075010
Name:ENGSTROM, KRISTEN MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:ENGSTROM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W VENETO CIR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-3625
Mailing Address - Country:US
Mailing Address - Phone:402-214-8946
Mailing Address - Fax:
Practice Address - Street 1:10800 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7758
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201341218RN163W00000X
NE66482163W00000X
OR201360040CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse