Provider Demographics
NPI:1790822682
Name:WALL, KRISTINA LAWRENCE (MEDICAID WAIVER PROV)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:LAWRENCE
Last Name:WALL
Suffix:
Gender:F
Credentials:MEDICAID WAIVER PROV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 HUMMINGBIRD ST APT B
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8059
Mailing Address - Country:US
Mailing Address - Phone:386-216-3317
Mailing Address - Fax:
Practice Address - Street 1:151 HUMMINGBIRD ST APT B
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-8059
Practice Address - Country:US
Practice Address - Phone:386-216-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689432196174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist