Provider Demographics
NPI:1083199301
Name:DIFERDINANDO, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DIFERDINANDO
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:PO BOX 1334
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1334
Mailing Address - Country:US
Mailing Address - Phone:575-776-2856
Mailing Address - Fax:
Practice Address - Street 1:203 LEDOUX ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7008
Practice Address - Country:US
Practice Address - Phone:575-776-2856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No175L00000XOther Service ProvidersHomeopath