Provider Demographics
NPI:1669452629
Name:PETERSON, KRISTEN JEANELLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:JEANELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:JEANELLE
Other - Last Name:NOLLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1599 N HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3180
Mailing Address - Country:US
Mailing Address - Phone:724-962-7920
Mailing Address - Fax:724-962-6029
Practice Address - Street 1:1599 N HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3180
Practice Address - Country:US
Practice Address - Phone:724-962-7920
Practice Address - Fax:724-962-6029
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA220033OtherHEALTH AMERICA/HEALTH ASSURANC
PA724159OtherHELATH AMERICA/HEATH ASSURANCE
PA104392OtherUPMC
PA1983093OtherHIGHMARK GROUP
PA579COtherUPMC
PA1016314280001Medicaid
PA1762971OtherHIGHMARK
PA548783OtherHIGHMARK GROUP
PA025221OtherMEDICARE GROUP
PA1016314280002Medicaid
PA118111OtherMEDICARE GROUP
PA104392OtherUPMC
PA1983093OtherHIGHMARK GROUP
PA095209XCGMedicare PIN