Provider Demographics
NPI:1497122212
Name:NIESTROM, KRISTINE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:NIESTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:7191 S KINGERY HWY
Practice Address - Street 2:STE L6
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5525
Practice Address - Country:US
Practice Address - Phone:630-455-6630
Practice Address - Fax:630-455-6631
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400238497Medicare PIN