Provider Demographics
NPI:1477960763
Name:FONSECA, KRISTIN SCHICK (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:SCHICK
Last Name:FONSECA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 GOODMAN RD E STE B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-1959
Mailing Address - Fax:662-510-2391
Practice Address - Street 1:726 GOODMAN RD E STE B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-1959
Practice Address - Fax:662-510-2391
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3193152W00000X
MS987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist