Provider Demographics
NPI:1164010542
Name:KRISTIANSEN, CHARITY L
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:L
Last Name:KRISTIANSEN
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 1:303 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-1610
Mailing Address - Country:US
Mailing Address - Phone:567-225-4788
Mailing Address - Fax:
Practice Address - Street 1:303 MAIN ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1610
Practice Address - Country:US
Practice Address - Phone:567-225-4788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6202166Medicaid
OH12345Medicaid