Provider Demographics
NPI:1043293376
Name:TAIVALMAA, KRISTINE S (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:S
Last Name:TAIVALMAA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8424
Practice Address - Fax:920-926-8389
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5427208000000X
WI42205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI01F1OtherJOHN DEERE
WI12560OtherDEAN
WI33332600Medicaid
WI390807236FAOtherUNITY
WIWI01F1OtherJOHN DEERE
H16285Medicare UPIN