Provider Demographics
NPI:1578874814
Name:DESAUTEL, KRISTEN KINGSBURY (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:KINGSBURY
Last Name:DESAUTEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANNE
Other - Last Name:KINGSBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5980 NEAL AVE N STE 500
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2195
Mailing Address - Country:US
Mailing Address - Phone:651-998-2020
Mailing Address - Fax:651-342-1407
Practice Address - Street 1:5980 NEAL AVE N STE 500
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-2195
Practice Address - Country:US
Practice Address - Phone:651-998-2020
Practice Address - Fax:651-342-1407
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3201152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist