Provider Demographics
NPI:1164826103
Name:PORT, KRISTINA (CNIM)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:PORT
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33518 HALEY RD # 1
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-5110
Mailing Address - Country:US
Mailing Address - Phone:888-344-2947
Mailing Address - Fax:281-622-4381
Practice Address - Street 1:33518 HALEY RD # 1
Practice Address - Street 2:
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484-5110
Practice Address - Country:US
Practice Address - Phone:888-344-2947
Practice Address - Fax:281-622-4381
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
292OtherR EEG T
199OtherR EP T
450OtherCNIM