Provider Demographics
NPI:1063586907
Name:IACUESSA, KRISTIE A (AUD)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:A
Last Name:IACUESSA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:A
Other - Last Name:DION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-A
Mailing Address - Street 1:163 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6720
Mailing Address - Country:US
Mailing Address - Phone:207-846-1380
Mailing Address - Fax:207-846-9701
Practice Address - Street 1:163 MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6720
Practice Address - Country:US
Practice Address - Phone:207-846-1380
Practice Address - Fax:207-846-9701
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP1251, DL20000389237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME274460099Medicaid
ME3207069OtherAETNA
ME060404OtherBLUE CROSS
ME274460099Medicaid
MEP00431673Medicare PIN