Provider Demographics
NPI:1922390467
Name:ROLLER-BAUKNECHT, KRISTIE RENAE
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:RENAE
Last Name:ROLLER-BAUKNECHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:RENAE
Other - Last Name:ROLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:MC 2433
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-1530
Mailing Address - Country:US
Mailing Address - Phone:608-662-0817
Mailing Address - Fax:608-203-4544
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:MC 2433
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-1530
Practice Address - Country:US
Practice Address - Phone:608-662-0817
Practice Address - Fax:608-203-4544
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13299-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist