Provider Demographics
NPI:1033600663
Name:WEGNER, KRISTA IRENE I
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:IRENE
Last Name:WEGNER
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 HAMAN WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-7507
Mailing Address - Country:US
Mailing Address - Phone:916-743-1932
Mailing Address - Fax:
Practice Address - Street 1:5620 BIRDCAGE ST STE 230
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7632
Practice Address - Country:US
Practice Address - Phone:510-670-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician