Provider Demographics
NPI:1861884264
Name:GROSSMAN, KRISTIN ELIZABETH (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 RONNIES PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-3552
Practice Address - Country:US
Practice Address - Phone:314-989-6807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11770-33363L00000X
KSF0215537363LF0000X
MOF0215537363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861884264Medicaid