Provider Demographics
NPI:1558046722
Name:WIEDER, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WIEDER
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 1:505 W 100 S APT 258
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2129
Mailing Address - Country:US
Mailing Address - Phone:385-290-2347
Mailing Address - Fax:
Practice Address - Street 1:505 W 100 S APT 258
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2129
Practice Address - Country:US
Practice Address - Phone:385-290-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11377011-3101164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse