Healthcare Provider Details

I. General information

NPI: 1396373593
Provider Name (Legal Business Name): KRISTINA LOUISE ESTUDILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 BROAD ST
SUMMERSVILLE WV
26651-1796
US

IV. Provider business mailing address

1703 WILDERNESS HWY
MOUNT NEBO WV
26679-9307
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-2090
  • Fax: 304-872-2574
Mailing address:
  • Phone: 304-222-9151
  • Fax: 304-872-2574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: