Provider Demographics
NPI:1710008867
Name:WISGIRDA, KRISTIN E (LIC AC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:WISGIRDA
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LIBERTY ST
Mailing Address - Street 2:UNIT 13B
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7500
Mailing Address - Country:US
Mailing Address - Phone:508-427-6575
Mailing Address - Fax:
Practice Address - Street 1:130 LIBERTY ST
Practice Address - Street 2:UNIT 13B
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7500
Practice Address - Country:US
Practice Address - Phone:508-427-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203605171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist