Provider Demographics
NPI:1821360967
Name:VAN ESS, KRISTINE MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:MARIE
Last Name:VAN ESS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:HYLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:N6162 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-4326
Mailing Address - Country:US
Mailing Address - Phone:920-893-9727
Mailing Address - Fax:
Practice Address - Street 1:7135 ROCKY KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073
Practice Address - Country:US
Practice Address - Phone:920-893-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1427-26171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator