Provider Demographics
NPI:1649675307
Name:FANGMAN, KRISTINE (MS CFY SLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:FANGMAN
Suffix:
Gender:F
Credentials:MS CFY SLP
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:M
Other - Last Name:PIPER-FANGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3307 MACKINAC CT
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-2353
Mailing Address - Country:US
Mailing Address - Phone:563-506-2737
Mailing Address - Fax:
Practice Address - Street 1:2109 CEDARWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-2670
Practice Address - Country:US
Practice Address - Phone:563-263-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075144235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist