Basic Information
| Provider Information | |||||||||
| NPI: | 1356652861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAKEMAN | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | ST CLOUD HOSPITAL | ||||||||
| Address2: | 1406 6TH AVENUE NORTH | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567115 | ||||||||
| Practice Location | |||||||||
| Address1: | ST CLOUD HOSPITAL | ||||||||
| Address2: | 1406 6TH AVENUE NORTH | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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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 | 8511 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 64-10926 | 01 | MN | SELECT CARE | OTHER | 1356652861 | 05 | MN | MEDICAID | 64-10926 | 01 | MN | MEDICA | OTHER | 1356652861 | 01 | MN | BLUE CROSS BLUE SHIELD OF MN | OTHER |