Provider Demographics
NPI:1821413519
Name:MOSTROM, KRISTEN LYN (MPA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYN
Last Name:MOSTROM
Suffix:
Gender:F
Credentials:MPA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 WARREN CARROLL DR BOX 8502
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27695-0001
Mailing Address - Country:US
Mailing Address - Phone:919-513-7801
Mailing Address - Fax:919-513-0728
Practice Address - Street 1:2500 WARREN CARROLL DR BOX 8502
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27695-0001
Practice Address - Country:US
Practice Address - Phone:919-513-7801
Practice Address - Fax:919-513-0728
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2307246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other