Provider Demographics
NPI:1275967713
Name:IVANOV, KAITLYN N (PT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:N
Last Name:IVANOV
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:N
Other - Last Name:HAMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12 PORTWALK PL
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-4086
Mailing Address - Country:US
Mailing Address - Phone:603-431-4200
Mailing Address - Fax:603-431-4202
Practice Address - Street 1:12 PORTWALK PL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-431-4200
Practice Address - Fax:603-431-4202
Is Sole Proprietor?:No
Enumeration Date:2013-08-31
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3116508Medicaid