Provider Demographics
NPI:1427870633
Name:MESTROM, KATJA ALIDA
Entity type:Individual
Prefix:
First Name:KATJA
Middle Name:ALIDA
Last Name:MESTROM
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 1:306 VILLAGE GREEN BLVD APT 103
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-3626
Mailing Address - Country:US
Mailing Address - Phone:616-808-6770
Mailing Address - Fax:
Practice Address - Street 1:306 VILLAGE GREEN BLVD APT 103
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-3626
Practice Address - Country:US
Practice Address - Phone:616-808-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program