Provider Demographics
NPI:1598895880
Name:WELLS, KRISTIN R (MS)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:WELLS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2783 RIDGEWAY DR SE
Mailing Address - Street 2:
Mailing Address - City:TURNER
Mailing Address - State:OR
Mailing Address - Zip Code:97392-9370
Mailing Address - Country:US
Mailing Address - Phone:541-913-4740
Mailing Address - Fax:503-362-8630
Practice Address - Street 1:2783 RIDGEWAY DR SE
Practice Address - Street 2:
Practice Address - City:TURNER
Practice Address - State:OR
Practice Address - Zip Code:97392-9370
Practice Address - Country:US
Practice Address - Phone:541-913-4740
Practice Address - Fax:503-362-8630
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA008OtherTRICARE NW
OR026648000OtherBLUE CROSS BLUE SHIELD
OR247332Medicaid
OR116186Medicare UPIN