Provider Demographics
NPI:1184014508
Name:WALSH, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WALSH
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 1:5145 RIVERFRONT DR
Mailing Address - Street 2:APT A
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5145 RIVERFRONT DR
Practice Address - Street 2:APT A
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5218
Practice Address - Country:US
Practice Address - Phone:386-569-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-24
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI32847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPSI32847OtherFLORIDA DEPARTMENT OF HEALTH