Provider Demographics
NPI:1871273177
Name:MOEN, KRISTY LYNN (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:MOEN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:LYNN
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:54524 344TH ST
Mailing Address - Street 2:
Mailing Address - City:WARROAD
Mailing Address - State:MN
Mailing Address - Zip Code:56763-9174
Mailing Address - Country:US
Mailing Address - Phone:218-766-2545
Mailing Address - Fax:
Practice Address - Street 1:1217 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5113
Practice Address - Country:US
Practice Address - Phone:218-755-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2207610163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse