Provider Demographics
NPI:1639292717
Name:VANWATTEGHEM, KRISTEN D
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:D
Last Name:VANWATTEGHEM
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 1:701 MANATEE AVE W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8604
Mailing Address - Country:US
Mailing Address - Phone:941-749-5222
Mailing Address - Fax:941-749-1839
Practice Address - Street 1:701 MANATEE AVE W
Practice Address - Street 2:SUITE 201
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8604
Practice Address - Country:US
Practice Address - Phone:941-749-5222
Practice Address - Fax:941-749-1839
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY0000946231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4456914001OtherBCBS PPO
FLS1940OtherBCBS
FLS1940ZMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL PROV