Healthcare Provider Details

I. General information

NPI: 1245304286
Provider Name (Legal Business Name): KRISTINE MARIE WILKE A.T.C-L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST SPORTS MEDICINE DEPT
DULUTH MN
55805-1951
US

IV. Provider business mailing address

2609 N 21ST ST APARTMENT #4
SUPERIOR WI
54880-7330
US

V. Phone/Fax

Practice location:
  • Phone: 715-395-4641
  • Fax:
Mailing address:
  • Phone: 218-340-9726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number642-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: