Provider Demographics
NPI:1992239842
Name:KNETZER, KRISTINE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:KNETZER
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 1:107 TOMMY HENRICH DR NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647-5402
Mailing Address - Country:US
Mailing Address - Phone:330-832-9582
Mailing Address - Fax:330-833-7732
Practice Address - Street 1:107 TOMMY HENRICH DR NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5402
Practice Address - Country:US
Practice Address - Phone:330-832-9582
Practice Address - Fax:330-833-7732
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH369129251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0160587Medicaid
OH0160587Medicaid