Provider Demographics
NPI:1912219445
Name:MOSEMAN, KRISTIN L (OD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:MOSEMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:L
Other - Last Name:BERTELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:740 REENA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3145
Mailing Address - Country:US
Mailing Address - Phone:920-563-8468
Mailing Address - Fax:920-563-9061
Practice Address - Street 1:740 REENA AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3145
Practice Address - Country:US
Practice Address - Phone:920-563-8468
Practice Address - Fax:920-563-9061
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3187-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist