Provider Demographics
NPI:1063020188
Name:CRAVENER, KRISTINE KAISER (BS)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:KAISER
Last Name:CRAVENER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 BECKMAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2499
Mailing Address - Country:US
Mailing Address - Phone:386-566-0444
Mailing Address - Fax:
Practice Address - Street 1:1095 BECKMAN DR
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2499
Practice Address - Country:US
Practice Address - Phone:386-566-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104283300Medicaid