Provider Demographics
NPI:1134210776
Name:HIESHETTER, KRISTIN ANNE (DC)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ANNE
Last Name:HIESHETTER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:ANNE
Other - Last Name:MCDONOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:207 W. JOHN ST.
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1209
Mailing Address - Country:US
Mailing Address - Phone:906-291-5080
Mailing Address - Fax:906-291-5081
Practice Address - Street 1:207 W. JOHN ST.
Practice Address - Street 2:PO 398
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1209
Practice Address - Country:US
Practice Address - Phone:906-291-5080
Practice Address - Fax:906-291-5081
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4128-012111N00000X
MI2301009094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP628001OtherPTAN
WI000101526Medicare ID - Type Unspecified
MIP628001OtherPTAN