Provider Demographics
NPI:1043708233
Name:MIKOLICH, KRISTA KATHLEEN
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:KATHLEEN
Last Name:MIKOLICH
Suffix:
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 1:462 GRIDER STREET
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215
Mailing Address - Country:US
Mailing Address - Phone:716-898-3941
Mailing Address - Fax:716-898-3279
Practice Address - Street 1:462 GRIDER STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-898-3941
Practice Address - Fax:716-898-3279
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program