Provider Demographics
NPI:1932481744
Name:WALDHAUER, KRISTA (BS)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:
Last Name:WALDHAUER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HILLSIDE PL
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1911
Mailing Address - Country:US
Mailing Address - Phone:631-239-5252
Mailing Address - Fax:
Practice Address - Street 1:32 HILLSIDE PL
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1911
Practice Address - Country:US
Practice Address - Phone:631-239-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008449-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist