Provider Demographics
NPI:1295207512
Name:FOURNIER, KRISTA MARIE
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:MARIE
Last Name:FOURNIER
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 1:22830 DOREMUS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2707
Mailing Address - Country:US
Mailing Address - Phone:248-250-4347
Mailing Address - Fax:
Practice Address - Street 1:22830 DOREMUS ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2707
Practice Address - Country:US
Practice Address - Phone:248-250-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704297753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered