Provider Demographics
NPI:1447870290
Name:MITCH, KRISTA JOANNE (FNP)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JOANNE
Last Name:MITCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 W WABANSIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4923
Mailing Address - Country:US
Mailing Address - Phone:773-517-3271
Mailing Address - Fax:
Practice Address - Street 1:3212 W WABANSIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4923
Practice Address - Country:US
Practice Address - Phone:773-517-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041437794163W00000X
IL209022698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse