Provider Demographics
NPI:1396373593
Name:ESTUDILLO, KRISTINA LOUISE
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LOUISE
Last Name:ESTUDILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 WILDERNESS HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT NEBO
Mailing Address - State:WV
Mailing Address - Zip Code:26679-9307
Mailing Address - Country:US
Mailing Address - Phone:304-222-9151
Mailing Address - Fax:304-872-2574
Practice Address - Street 1:804 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1796
Practice Address - Country:US
Practice Address - Phone:304-872-2090
Practice Address - Fax:304-872-2574
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator