Provider Demographics
NPI:1558757385
Name:GULLEY, KRISTINE MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:MARIE
Last Name:GULLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:201 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:41097-9458
Mailing Address - Country:US
Mailing Address - Phone:859-824-7803
Mailing Address - Fax:
Practice Address - Street 1:201 KIMBERLY LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:KY
Practice Address - Zip Code:41097-9458
Practice Address - Country:US
Practice Address - Phone:859-824-7803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03146225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant