Provider Demographics
NPI:1174074116
Name:KIVLEN, KRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KIVLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-9516
Mailing Address - Country:US
Mailing Address - Phone:802-371-4100
Mailing Address - Fax:301-797-4234
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4100
Practice Address - Fax:301-797-4234
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06245363A00000X
PAMA058666363A00000X
MDC0006245363AS0400X
VT055.0031631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical