Provider Demographics
NPI:1043460413
Name:AVERELL, KRIS (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:
Last Name:AVERELL
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 RIDGEMOOR CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8111
Mailing Address - Country:US
Mailing Address - Phone:502-228-5776
Mailing Address - Fax:
Practice Address - Street 1:3103 RIDGEMOOR CT
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8111
Practice Address - Country:US
Practice Address - Phone:502-228-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3826171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor