Provider Demographics
NPI:1114470127
Name:BOUR, KRISTINE K
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:K
Last Name:BOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TAYLOR AVE
Mailing Address - Street 2:205
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4527
Mailing Address - Country:US
Mailing Address - Phone:931-456-5757
Mailing Address - Fax:931-456-5533
Practice Address - Street 1:29 TAYLOR AVE
Practice Address - Street 2:205
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4527
Practice Address - Country:US
Practice Address - Phone:931-456-5757
Practice Address - Fax:931-456-5533
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6280225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6280OtherSTATE LICENSE