Provider Demographics
NPI:1538432513
Name:BLOUGH, KRISTA LEE (APRN)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEE
Last Name:BLOUGH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:LEE
Other - Last Name:GOLDSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1002 RUMSEY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3533
Mailing Address - Country:US
Mailing Address - Phone:307-395-7510
Mailing Address - Fax:307-395-7511
Practice Address - Street 1:1002 RUMSEY AVE STE A
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3533
Practice Address - Country:US
Practice Address - Phone:307-395-7510
Practice Address - Fax:307-395-7511
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19373.1191364SP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health