Provider Demographics
NPI:1851991947
Name:KRISTIANSEN, GINA MARIE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:KRISTIANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 HUALAPAI MOUNTAIN RD STE C
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6207
Mailing Address - Country:US
Mailing Address - Phone:928-565-6655
Mailing Address - Fax:928-565-6578
Practice Address - Street 1:2331 HUALAPAI MOUNTAIN RD STE C
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6207
Practice Address - Country:US
Practice Address - Phone:928-565-6655
Practice Address - Fax:928-565-6578
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ306033363LF0000X
TX1014793363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health