Basic Information
Provider Information | |||||||||
NPI: | 1457565228 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | KRISTINE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VUKELICH | ||||||||
OtherFirstName: | KRISTINE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | COTA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6458 CITY WEST PKWY | ||||||||
Address2: |   | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553443245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6127677222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6458 CITY WEST PKWY | ||||||||
Address2: |   | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553443245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6127677222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 04/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 201405 | MN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   | 225X00000X | 104701 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 201405 | 01 | MN | MN LICENSURE | OTHER | 104701 | 01 | MN | OT LICENSURE | OTHER |