Provider Demographics
NPI:1518333434
Name:PUKETZA, KRISTAN RICHARDSON (LAC)
Entity type:Individual
Prefix:
First Name:KRISTAN
Middle Name:RICHARDSON
Last Name:PUKETZA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 CHESTERFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1214
Mailing Address - Country:US
Mailing Address - Phone:304-395-3109
Mailing Address - Fax:
Practice Address - Street 1:3102 CHESTERFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1214
Practice Address - Country:US
Practice Address - Phone:304-395-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist