Provider Demographics
NPI:1730767302
Name:BLACK, KRISTEN ELAINE (CRNP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELAINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELAINE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:354 MILL ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6138
Mailing Address - Country:US
Mailing Address - Phone:301-676-0160
Mailing Address - Fax:
Practice Address - Street 1:8 ROUZER CT
Practice Address - Street 2:
Practice Address - City:THURMONT
Practice Address - State:MD
Practice Address - Zip Code:21788-1676
Practice Address - Country:US
Practice Address - Phone:301-676-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRN706137363LG0600X
MDR209202363LG0600X
PASP023459363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology