Provider Demographics
NPI:1942778543
Name:WENDT, KRISTINA M
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:WENDT
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 1:701 E COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2317
Mailing Address - Country:US
Mailing Address - Phone:801-910-6865
Mailing Address - Fax:
Practice Address - Street 1:701 E COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2317
Practice Address - Country:US
Practice Address - Phone:801-910-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2522225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist