Provider Demographics
NPI:1780011742
Name:WRAGG, KRISTI MAE (MD)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:MAE
Last Name:WRAGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:MAE
Other - Last Name:THERIAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1018 N CALDWELL ST APT 652
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3692
Mailing Address - Country:US
Mailing Address - Phone:704-302-7397
Mailing Address - Fax:
Practice Address - Street 1:5841 CORPORATE WAY STE 200
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2039
Practice Address - Country:US
Practice Address - Phone:561-684-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2024-10-06
Deactivation Date:2018-03-29
Deactivation Code:
Reactivation Date:2018-04-04
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
390200000X, 104100000X
FLME1701232084P0800X
NC2388412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4144007Medicaid
NJ4144007Medicaid