Provider Demographics
NPI:1306383914
Name:WOLLENZIN, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WOLLENZIN
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 1:1958 CEDAR RIVER CT
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7939
Mailing Address - Country:US
Mailing Address - Phone:904-304-2284
Mailing Address - Fax:
Practice Address - Street 1:1958 CEDAR RIVER CT
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-7939
Practice Address - Country:US
Practice Address - Phone:904-304-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-22
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA2799225X00000X
FLOTA12556225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist