Provider Demographics
NPI:1124355433
Name:WIDMAYER, KRISTEN ALEXANDRIA (DPT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ALEXANDRIA
Last Name:WIDMAYER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-0158
Mailing Address - Country:US
Mailing Address - Phone:252-726-4000
Mailing Address - Fax:
Practice Address - Street 1:147 HWY 24
Practice Address - Street 2:HESTRON PLAZA, SUITE 102
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557
Practice Address - Country:US
Practice Address - Phone:252-726-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist