Provider Demographics
NPI:1265905376
Name:SNYDER, KRISTEN MARIE (CG60913281)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:SNYDER
Suffix:
Gender:F
Credentials:CG60913281
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:FERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 N MARKET BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2677
Mailing Address - Country:US
Mailing Address - Phone:360-948-0288
Mailing Address - Fax:
Practice Address - Street 1:151 N MARKET BLVD STE D
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2677
Practice Address - Country:US
Practice Address - Phone:360-948-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60913281175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60913281Medicaid