Provider Demographics
NPI:1679058762
Name:WYMER, KRISTIN MARIE (NP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:WYMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9231
Mailing Address - Fax:
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-237-9231
Practice Address - Fax:574-204-6355
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28193580A163WR0006X
IN71008462A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN169380084OtherMEDICARE PTAN
IN247000032OtherMEDICARE PTAN
IN261970104OtherMEDICARE PTAN
IN300020098Medicaid