Provider Demographics
NPI:1356922298
Name:GRANT, KRISTINA R (DO)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:R
Last Name:GRANT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1337 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2046
Mailing Address - Country:US
Mailing Address - Phone:417-967-5435
Mailing Address - Fax:417-967-5503
Practice Address - Street 1:1337 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2046
Practice Address - Country:US
Practice Address - Phone:417-967-5435
Practice Address - Fax:417-967-5503
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024021247207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D0889777OtherCLIA
MO200142346Medicaid