Provider Demographics
NPI:1114567773
Name:BREWER, KRISTEN NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:BREWER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:NICOLE
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:300 KATHY DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802
Mailing Address - Country:US
Mailing Address - Phone:501-253-2804
Mailing Address - Fax:
Practice Address - Street 1:300 KATHY DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802
Practice Address - Country:US
Practice Address - Phone:501-253-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4404225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR237780721Medicaid