Provider Demographics
NPI:1053460055
Name:VANDERIET, KRISTIN MARIE (OTR)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:MARIE
Last Name:VANDERIET
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9573 QUEENSLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1236
Mailing Address - Country:US
Mailing Address - Phone:952-451-2394
Mailing Address - Fax:
Practice Address - Street 1:3395 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3765
Practice Address - Country:US
Practice Address - Phone:952-939-0396
Practice Address - Fax:952-548-8760
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102680174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist