Provider Demographics
NPI:1073772315
Name:WAFFLE, KRISTINE L (MS, PT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:L
Last Name:WAFFLE
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 UPLAND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2286
Mailing Address - Country:US
Mailing Address - Phone:260-341-0294
Mailing Address - Fax:260-489-8329
Practice Address - Street 1:827 UPLAND RIDGE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2286
Practice Address - Country:US
Practice Address - Phone:260-341-0294
Practice Address - Fax:260-489-8329
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002143A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics