Provider Demographics
NPI:1932891165
Name:PICKETT, KRISTINA M (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:PICKETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 WINDING RIDGE DR APT 3B
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7556
Mailing Address - Country:US
Mailing Address - Phone:614-512-4187
Mailing Address - Fax:
Practice Address - Street 1:1 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8065
Practice Address - Country:US
Practice Address - Phone:810-606-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23121072044208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery