Provider Demographics
NPI:1821072190
Name:HERISTCHI, KRISTEN LEIGH (MPH, PAC, CAQ-PSYCH)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:HERISTCHI
Suffix:
Gender:F
Credentials:MPH, PAC, CAQ-PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6961 INDIAN CREEK PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3833
Mailing Address - Country:US
Mailing Address - Phone:863-397-4259
Mailing Address - Fax:
Practice Address - Street 1:1801 CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5979
Practice Address - Country:US
Practice Address - Phone:863-709-8543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA910207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8856YOtherMEDICARE
P77389Medicare UPIN
E8856ZMedicare ID - Type Unspecified