Provider Demographics
NPI:1548479215
Name:TARDIF, KRISTI LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:TARDIF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:L
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, ATC
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT,
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-5985
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC,
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3694
Practice Address - Fax:904-697-3927
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106032363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006564600Medicaid
PA9106032OtherPA-C