Provider Demographics
NPI:1689192023
Name:IKEMORI, KRISTINA LYNNE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNNE
Last Name:IKEMORI
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:LYNNE
Other - Last Name:PARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 COBBS CV
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-8751
Mailing Address - Country:US
Mailing Address - Phone:662-869-0027
Mailing Address - Fax:
Practice Address - Street 1:119 COBBS CV
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-8751
Practice Address - Country:US
Practice Address - Phone:662-869-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist