Provider Demographics
NPI:1932401874
Name:FISK, KRISTINA JEAN
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:JEAN
Last Name:FISK
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 1:904 WINCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2720
Mailing Address - Country:US
Mailing Address - Phone:813-651-1461
Mailing Address - Fax:
Practice Address - Street 1:11964 BOYETTE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5601
Practice Address - Country:US
Practice Address - Phone:813-663-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor