Provider Demographics
NPI:1316983075
Name:BOMBOY, KRISTEN (APRN CNP)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:BOMBOY
Suffix:
Gender:F
Credentials:APRN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 BOREN BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-2050
Mailing Address - Country:US
Mailing Address - Phone:405-382-4507
Mailing Address - Fax:405-382-5269
Practice Address - Street 1:2010 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2050
Practice Address - Country:US
Practice Address - Phone:405-382-4507
Practice Address - Fax:405-382-5269
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN5739001363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019070AMedicaid