Provider Demographics
NPI:1902118789
Name:BOOTHE, KRISTIN P (APRN)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:P
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:P
Other - Last Name:FERRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:2609 NEW HARTFORD RD STE 3
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1316
Practice Address - Country:US
Practice Address - Phone:812-476-7111
Practice Address - Fax:812-476-7117
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1114048163W00000X
KY3006532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
12125026OtherCAQH
IN201006560Medicaid
KY7100124900Medicaid