Healthcare Provider Details

I. General information

NPI: 1720374127
Provider Name (Legal Business Name): KRISTINE MARIE AXTELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 10TH AVE
MENOMINEE MI
49858-3009
US

IV. Provider business mailing address

715 PYLE DR
KINGSFORD MI
49802-4456
US

V. Phone/Fax

Practice location:
  • Phone: 906-863-7841
  • Fax:
Mailing address:
  • Phone: 906-774-0522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704284146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: