Provider Demographics
NPI:1073013025
Name:PRIMLEY, KRISTA S
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:S
Last Name:PRIMLEY
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 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:2581 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4247
Practice Address - Country:US
Practice Address - Phone:920-347-0400
Practice Address - Fax:920-347-0868
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND142921223S0112X
IARES-30533390200000X
WI60013961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program