Provider Demographics
NPI:1871837021
Name:DISOGRA, KRISTYN YEMM
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:YEMM
Last Name:DISOGRA
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:PO BOX 356015
Mailing Address - Street 2:1959 NE PACIFIC STREET
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195
Mailing Address - Country:US
Mailing Address - Phone:206-598-6062
Mailing Address - Fax:
Practice Address - Street 1:4400 GOLF ACRES DR STE B1
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5976
Practice Address - Country:US
Practice Address - Phone:704-512-6057
Practice Address - Fax:704-512-6058
Is Sole Proprietor?:No
Enumeration Date:2012-11-11
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28487183500000X
MN122267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist