Provider Demographics
NPI:1780901595
Name:WOLFENBARGER, KRISTEN MARIE (DO)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:WOLFENBARGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:BROADHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:423 MEDICAL PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5641
Mailing Address - Country:US
Mailing Address - Phone:865-270-6600
Mailing Address - Fax:865-374-2102
Practice Address - Street 1:423 MEDICAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5641
Practice Address - Country:US
Practice Address - Phone:865-270-6600
Practice Address - Fax:865-374-2102
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000002801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1534541Medicaid
TN202I085831Medicare PIN