Provider Demographics
NPI:1649004144
Name:BOONIE, KRISTEN ROSE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ROSE
Last Name:BOONIE
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 1:350 E WILLOW GROVE AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-4428
Mailing Address - Country:US
Mailing Address - Phone:845-705-0794
Mailing Address - Fax:
Practice Address - Street 1:140 ALLENDALE RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2939
Practice Address - Country:US
Practice Address - Phone:610-265-0344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG004195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist