Provider Demographics
NPI:1578010740
Name:VAN STAALDUINEN, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:VAN STAALDUINEN
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 1:4353 E STATE ROUTE 73 STE 120
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-8814
Mailing Address - Country:US
Mailing Address - Phone:513-897-0085
Mailing Address - Fax:
Practice Address - Street 1:4353 E STATE ROUTE 73
Practice Address - Street 2:SUITE 120
Practice Address - City:WAYNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:45068-8812
Practice Address - Country:US
Practice Address - Phone:937-897-0085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH019760363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily