Provider Demographics
NPI:1972021590
Name:WICHERT, KRISTYANA
Entity Type:Individual
Prefix:
First Name:KRISTYANA
Middle Name:
Last Name:WICHERT
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 1:98 WESTCHESTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-259-8813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.163182.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse