Provider Demographics
NPI:1144411174
Name:SANDERSON, KRISTYN NICOLE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KRISTYN
Middle Name:NICOLE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2940
Mailing Address - Country:US
Mailing Address - Phone:920-676-2933
Mailing Address - Fax:
Practice Address - Street 1:960 S RAPIDS RD
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4146
Practice Address - Country:US
Practice Address - Phone:920-684-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1925027224Z00000X
WI5378-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant