Provider Demographics
NPI:1720894058
Name:ATWOOD, KRISTYANNA FREDERICKIA
Entity type:Individual
Prefix:
First Name:KRISTYANNA
Middle Name:FREDERICKIA
Last Name:ATWOOD
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 1:753 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4133
Mailing Address - Country:US
Mailing Address - Phone:320-291-4456
Mailing Address - Fax:
Practice Address - Street 1:1121 JACKSON ST NE STE 100
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-3051
Practice Address - Country:US
Practice Address - Phone:320-291-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL000121481900374J00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula