Provider Demographics
NPI:1578219184
Name:WALL, KRISTINE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:WALL
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:PO BOX 1124
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:81423-1124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 LUCERNE ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:CO
Practice Address - Zip Code:81423
Practice Address - Country:US
Practice Address - Phone:970-327-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant