Provider Demographics
NPI:1720589609
Name:KRIVULKA, KELLY MICHELE (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELE
Last Name:KRIVULKA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 DAIRY WAY
Mailing Address - Street 2:
Mailing Address - City:BUELLTON
Mailing Address - State:CA
Mailing Address - Zip Code:93427-9302
Mailing Address - Country:US
Mailing Address - Phone:805-245-5419
Mailing Address - Fax:
Practice Address - Street 1:5850 E STILL CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3618
Practice Address - Country:US
Practice Address - Phone:480-219-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA93650OtherNATIONAL ATHLETIC TRAINERS' ASSOCIATION
2000034465OtherBOC