Provider Demographics
NPI:1538464516
Name:WILSON, KRISTINA ANN (MA60186404)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA60186404
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 S FERRALL ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223
Mailing Address - Country:US
Mailing Address - Phone:509-448-3411
Mailing Address - Fax:
Practice Address - Street 1:3209 E 57TH AVE
Practice Address - Street 2:SUITE F
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223
Practice Address - Country:US
Practice Address - Phone:509-448-9398
Practice Address - Fax:509-232-5777
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60186404171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor