Provider Demographics
NPI:1376780056
Name:PETRY, KRISTIE R (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:R
Last Name:PETRY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3836
Mailing Address - Country:US
Mailing Address - Phone:715-526-5547
Mailing Address - Fax:715-526-5542
Practice Address - Street 1:504 LAKELAND RD
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3836
Practice Address - Country:US
Practice Address - Phone:715-526-5547
Practice Address - Fax:715-526-5542
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI162531-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse