Provider Demographics
NPI:1548516966
Name:BORMAN, KRISTINA LOUISE (NP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LOUISE
Last Name:BORMAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E THIRD ST MSS 6AV-1
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8319
Mailing Address - Fax:
Practice Address - Street 1:1502 LONDON ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812
Practice Address - Country:US
Practice Address - Phone:218-576-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2548363LF0000X
WI178477-30363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily