Provider Demographics
NPI:1477524031
Name:WAILGUM, KRISTINE K (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:K
Last Name:WAILGUM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:770 CONVERSE ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1719
Practice Address - Country:US
Practice Address - Phone:413-567-3949
Practice Address - Fax:413-567-0175
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110009363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8303930OtherEVERCARE
MA0710296Medicaid
MANP2697OtherBLUE CROSS
P14013Medicare UPIN
MAUX2001Medicare PIN
MA8303930OtherEVERCARE
MANP2697Medicare PIN