Provider Demographics
NPI:1902389638
Name:ELLISON, KRISTA A (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:A
Last Name:ELLISON
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2696
Mailing Address - Country:US
Mailing Address - Phone:304-925-4200
Mailing Address - Fax:304-925-0483
Practice Address - Street 1:1 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2696
Practice Address - Country:US
Practice Address - Phone:304-925-4200
Practice Address - Fax:304-925-0483
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN61701-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily