Provider Demographics
NPI:1104190966
Name:THOMPSON, KRISTEN SUE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:SUE
Last Name:THOMPSON
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:N9134 CHRISTOPHER LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-738-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-26
Last Update Date:2012-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1814-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant