Provider Demographics
NPI:1790364750
Name:WATANABE, KRISTINA (NBC-HWP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WATANABE
Suffix:
Gender:F
Credentials:NBC-HWP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 MONUMENT SQ STE 209
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1013
Mailing Address - Country:US
Mailing Address - Phone:262-770-5216
Mailing Address - Fax:
Practice Address - Street 1:524 MONUMENT SQ STE 209
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1013
Practice Address - Country:US
Practice Address - Phone:262-770-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date: