Provider Demographics
NPI:1699195198
Name:BALLARD, KRYSTEN MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:KRYSTEN
Middle Name:MICHELLE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SW NELSON DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029
Mailing Address - Country:US
Mailing Address - Phone:816-809-1128
Mailing Address - Fax:
Practice Address - Street 1:3980 SOUTH JACKSON DRIVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-795-1433
Practice Address - Fax:816-795-1766
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO228022459225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant