Provider Demographics
NPI:1821394396
Name:ROSEQUIST, KRISTIN KAY
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KAY
Last Name:ROSEQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7473 W LAKE MEAD BLVD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0265
Mailing Address - Country:US
Mailing Address - Phone:702-562-1248
Mailing Address - Fax:702-562-1249
Practice Address - Street 1:7473 W LAKE MEAD BLVD
Practice Address - Street 2:SUITE 21
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0265
Practice Address - Country:US
Practice Address - Phone:702-562-1248
Practice Address - Fax:702-562-1249
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid