Healthcare Provider Details

I. General information

NPI: 1588173843
Provider Name (Legal Business Name): KRISTINA WADDLE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PARK AVE
IRONTON OH
45638-1502
US

IV. Provider business mailing address

PO BOX 108
IRONTON OH
45638-0108
US

V. Phone/Fax

Practice location:
  • Phone: 740-532-1613
  • Fax: 740-532-1715
Mailing address:
  • Phone: 740-531-1613
  • Fax: 740-532-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0022124
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: