Provider Demographics
NPI:1306071444
Name:NIEHANKE, KRISTINA N (NP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:N
Last Name:NIEHANKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W CRANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2930
Mailing Address - Country:US
Mailing Address - Phone:229-247-7350
Mailing Address - Fax:229-242-1730
Practice Address - Street 1:105 W CRANFORD AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2930
Practice Address - Country:US
Practice Address - Phone:229-247-7350
Practice Address - Fax:229-468-0042
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN143057363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid