Provider Demographics
NPI:1578559514
Name:WAMBEKE, KRISTI A (PT)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:A
Last Name:WAMBEKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:635 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-2963
Practice Address - Country:US
Practice Address - Phone:815-772-7274
Practice Address - Fax:815-772-4590
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19402651225100000X
IL070010236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI18344Medicare PIN
IL555640Medicare PIN