Provider Demographics
NPI:1699205864
Name:WAITE, KRISTEN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:WAITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 AQUA MARINE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2569
Mailing Address - Country:US
Mailing Address - Phone:440-465-1999
Mailing Address - Fax:
Practice Address - Street 1:272 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2374
Practice Address - Country:US
Practice Address - Phone:419-668-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005250RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant