Basic Information
| Provider Information | |||||||||
| NPI: | 1770818213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROOU | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152845150 | ||||||||
| Practice Location | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152845150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2009 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 115937 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3883 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 100006296 | 05 | WI | MEDICAID |