Provider Demographics
NPI:1992272298
Name:BALLARD, KRISTINA (DNP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MEDICAL CENTER DR STE 2350
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2780
Mailing Address - Country:US
Mailing Address - Phone:207-373-6690
Mailing Address - Fax:
Practice Address - Street 1:81 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2764
Practice Address - Country:US
Practice Address - Phone:207-373-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139483363LA2100X
MECNP211532363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX391311301Medicaid