Provider Demographics
NPI:1447424874
Name:PACHECO, KRISTIN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:PACHECO
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:PO BOX 1097
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-1097
Mailing Address - Country:US
Mailing Address - Phone:701-444-5221
Mailing Address - Fax:
Practice Address - Street 1:1415 W DAKOTA PKWY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3885
Practice Address - Country:US
Practice Address - Phone:701-572-6757
Practice Address - Fax:401-774-3532
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND855235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55201Medicaid
ND855OtherSTATE LICENSE