Provider Demographics
NPI:1699258483
Name:VANNATTA, KRISTINA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ANN
Last Name:VANNATTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11541 E WINCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2040
Mailing Address - Country:US
Mailing Address - Phone:443-996-4400
Mailing Address - Fax:317-582-8852
Practice Address - Street 1:8240 NAAB RD STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1985
Practice Address - Country:US
Practice Address - Phone:317-338-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN1000240A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical