Provider Demographics
NPI:1366839615
Name:WILLYARD, KRISTINA (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WILLYARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2786 56TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8708
Mailing Address - Country:US
Mailing Address - Phone:616-261-3960
Mailing Address - Fax:
Practice Address - Street 1:2786 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8708
Practice Address - Country:US
Practice Address - Phone:616-261-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist