Provider Demographics
NPI:1790777431
Name:HALL, KRISTINE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:HALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:871 E SAWGRASS TRL
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5198
Mailing Address - Country:US
Mailing Address - Phone:712-574-4470
Mailing Address - Fax:
Practice Address - Street 1:871 E SAWGRASS TRL
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5198
Practice Address - Country:US
Practice Address - Phone:712-574-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1284225100000X
SD0986225100000X
IA004453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503513Medicaid
NV100503513Medicaid