Provider Demographics
NPI:1679823546
Name:SCALDONE, KRISTIE (CSA)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:SCALDONE
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 GRIMES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4614
Mailing Address - Country:US
Mailing Address - Phone:770-985-4257
Mailing Address - Fax:770-985-4258
Practice Address - Street 1:749 GRIMES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4614
Practice Address - Country:US
Practice Address - Phone:770-985-4257
Practice Address - Fax:770-985-4258
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA61477208600000X
363AS0400X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA800806828OtherTAX ID #