Provider Demographics
NPI:1093815748
Name:KISTLER, JILL RENEE (ATC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:RENEE
Last Name:KISTLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1399 MILLIKIN PL NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-4451
Mailing Address - Country:US
Mailing Address - Phone:330-372-4580
Mailing Address - Fax:
Practice Address - Street 1:1296 TOD PL NW
Practice Address - Street 2:SUITE 208
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2474
Practice Address - Country:US
Practice Address - Phone:330-306-5018
Practice Address - Fax:330-306-5021
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0006222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer