Provider Demographics
NPI:1477676799
Name:WIENEKE, KRISTA JEAN
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:JEAN
Last Name:WIENEKE
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 1:2031 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14440 28TH PL N STE 200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4854
Practice Address - Country:US
Practice Address - Phone:612-707-0169
Practice Address - Fax:612-465-1603
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist