Provider Demographics
NPI:1245304286
Name:WILKE, KRISTINE MARIE (ATC-L)
Entity type:Individual
Prefix:MISS
First Name:KRISTINE
Middle Name:MARIE
Last Name:WILKE
Suffix:
Gender:F
Credentials:ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 N 21ST ST
Mailing Address - Street 2:APARTMENT #4
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-7330
Mailing Address - Country:US
Mailing Address - Phone:218-340-9726
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:SPORTS MEDICINE DEPT
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:715-395-4641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI642-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI642-039OtherWISCONSIN LICENSE NUMBER