Provider Demographics
NPI:1235967720
Name:CRODDY, KRISTINA (PHMNP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:CRODDY
Suffix:
Gender:F
Credentials:PHMNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2730
Mailing Address - Country:US
Mailing Address - Phone:317-374-7764
Mailing Address - Fax:
Practice Address - Street 1:6720 PARKDALE PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4668
Practice Address - Country:US
Practice Address - Phone:317-744-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015614A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health