Provider Demographics
NPI:1114463494
Name:KANDZERSKI, KRISTEN LEE (LMT)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:LEE
Last Name:KANDZERSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:HOPE VALLEY
Mailing Address - State:RI
Mailing Address - Zip Code:02832-2023
Mailing Address - Country:US
Mailing Address - Phone:401-374-0834
Mailing Address - Fax:
Practice Address - Street 1:5 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:HOPE VALLEY
Practice Address - State:RI
Practice Address - Zip Code:02832-2023
Practice Address - Country:US
Practice Address - Phone:401-374-0834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT00982172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker