Healthcare Provider Details

I. General information

NPI: 1790079200
Provider Name (Legal Business Name): KRISTIN CRAKER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S WEBB ST
WITTENBERG WI
54499-9040
US

IV. Provider business mailing address

604 S WEBB ST
WITTENBERG WI
54499-9040
US

V. Phone/Fax

Practice location:
  • Phone: 715-253-2037
  • Fax: 715-253-2056
Mailing address:
  • Phone: 715-253-2037
  • Fax: 715-253-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1120-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: