Provider Demographics
NPI:1427242650
Name:KATINKA, KRISTINA M (MSOM LAC)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:M
Last Name:KATINKA
Suffix:
Gender:F
Credentials:MSOM LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 W BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3502
Mailing Address - Country:US
Mailing Address - Phone:208-412-5412
Mailing Address - Fax:
Practice Address - Street 1:1080 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3502
Practice Address - Country:US
Practice Address - Phone:208-412-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist