Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 05002143A | IN |
NPI | 1073772315 |
---|---|
Provider Name | Kristine L. Waffle |
First Address | Fort Wayne, IN 46825-2286 |
Second Address | Fort Wayne, IN 46825-2286 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2008 |
Last Update Date | 02/06/2008 |