Provider Demographics
NPI:1053384073
Name:HADDOCK, KRISTIN BRAVEBOY (APRN)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:BRAVEBOY
Last Name:HADDOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-648-7774
Mailing Address - Fax:
Practice Address - Street 1:420 SOCIETY HILL DR STE 100
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-1731
Practice Address - Country:US
Practice Address - Phone:803-648-7774
Practice Address - Fax:803-648-7490
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0888Medicaid
SCQ428589636Medicare PIN
SCNP0888Medicaid