Provider Demographics
NPI:1790254464
Name:ELLISON, KRISTEN M
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:ELLISON
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 1:801 CREST PARK PT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-2699
Mailing Address - Country:US
Mailing Address - Phone:352-356-1603
Mailing Address - Fax:
Practice Address - Street 1:125 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2354
Practice Address - Country:US
Practice Address - Phone:352-356-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-25
Last Update Date:2018-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006789225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist