Provider Demographics
NPI:1356667604
Name:PETREY, KRISTINE ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:PETREY
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 1:22 THE SQUARE AT LILLINGTON
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-8030
Mailing Address - Country:US
Mailing Address - Phone:910-893-2850
Mailing Address - Fax:888-867-7402
Practice Address - Street 1:22 THE SQUARE AT LILLINGTON
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-8030
Practice Address - Country:US
Practice Address - Phone:910-893-2850
Practice Address - Fax:888-867-7402
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4292225200000X
KYA02428225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant