Provider Demographics
NPI:1396746632
Name:LEGNOLA, KRISTIN MARCUSSEN (DC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARCUSSEN
Last Name:LEGNOLA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:L
Other - Last Name:MARCUSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1717 SWEDE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-3375
Mailing Address - Country:US
Mailing Address - Phone:484-688-0664
Mailing Address - Fax:484-688-0667
Practice Address - Street 1:1717 SWEDE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-3375
Practice Address - Country:US
Practice Address - Phone:484-688-0664
Practice Address - Fax:484-688-0667
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006990-L111N00000X
NJ38MC00582500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA857531OtherAETNA PIN
PA951592Medicare ID - Type Unspecified
PA857531OtherAETNA PIN