Provider Demographics
NPI:1619204450
Name:KISTLER, MICHELLE DESJARLAIS (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DESJARLAIS
Last Name:KISTLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 MOBILE DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-9021
Mailing Address - Country:US
Mailing Address - Phone:541-301-6765
Mailing Address - Fax:541-482-3364
Practice Address - Street 1:208 OAK ST STE 304
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1872
Practice Address - Country:US
Practice Address - Phone:541-292-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist