Provider Demographics
NPI:1013356773
Name:BLUNDELL, KRISTAL LEE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:LEE
Last Name:BLUNDELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-2203
Mailing Address - Country:US
Mailing Address - Phone:928-230-2715
Mailing Address - Fax:
Practice Address - Street 1:1515 LAKE HAVASU AVE N STE 100
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-1177
Practice Address - Country:US
Practice Address - Phone:928-854-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10274APTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant