1134210776 NPI number — DR. KRISTIN ANNE HIESHETTER D.C.

Table of content: DR. KRISTIN ANNE HIESHETTER D.C. (NPI 1134210776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134210776 NPI number — DR. KRISTIN ANNE HIESHETTER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIESHETTER
Provider First Name:
KRISTIN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCDONOUGH
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134210776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 398
Provider Second Line Business Mailing Address:
207 W. JOHN ST.
Provider Business Mailing Address City Name:
NEWBERRY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49868-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-291-5080
Provider Business Mailing Address Fax Number:
906-291-5081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 W. JOHN ST.
Provider Second Line Business Practice Location Address:
PO 398
Provider Business Practice Location Address City Name:
NEWBERRY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49868-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-291-5080
Provider Business Practice Location Address Fax Number:
906-291-5081
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4128-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 2301009094 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P628001 . This is a "PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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