Provider Demographics
NPI:1427649524
Name:WILLIS, KRISTEN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WILLIS
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 1:443 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:12117-3416
Mailing Address - Country:US
Mailing Address - Phone:518-774-6008
Mailing Address - Fax:
Practice Address - Street 1:19 CLIFTON COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3881
Practice Address - Country:US
Practice Address - Phone:518-280-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000053003237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist