Basic Information
| Provider Information | |||||||||
| NPI: | 1174668347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NASH | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | W163S7765 SEAFARER PASS | ||||||||
| Address2: | |||||||||
| City: | MUSKEGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531508642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144228626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4448 W LOOMIS RD | ||||||||
| Address2: | #205 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532204800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142815151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6485 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40449600 | 05 | WI | MEDICAID |