Basic Information
Provider Information | |||||||||
NPI: | 1144214248 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALZ | ||||||||
FirstName: | KRISTI | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENSEN | ||||||||
OtherFirstName: | KRISTI | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5410 | ||||||||
Address2: | 1021 NEBRASKA ST | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511025410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122522477 | ||||||||
FaxNumber: | 7122525516 | ||||||||
Practice Location | |||||||||
Address1: | 1021 NEBRASKA ST | ||||||||
Address2: |   | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511051436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122522477 | ||||||||
FaxNumber: | 7122525920 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2005 | ||||||||
LastUpdateDate: | 06/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33620 | IA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.