Provider Demographics
NPI:1144727934
Name:VANDERWIJST, KRISTEN LANE (DPT)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LANE
Last Name:VANDERWIJST
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11717 HARRIS MILL CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-1890
Mailing Address - Country:US
Mailing Address - Phone:757-374-9839
Mailing Address - Fax:
Practice Address - Street 1:4701 SPOTSYLVANIA PKWY STE 106
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-9435
Practice Address - Country:US
Practice Address - Phone:540-710-0100
Practice Address - Fax:540-710-5333
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist