Provider Demographics
NPI:1861663023
Name:BOLL, KRISTIE L (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:L
Last Name:BOLL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:L
Other - Last Name:GRAVEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:321 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PROPHETSTOWN
Practice Address - State:IL
Practice Address - Zip Code:61277-1105
Practice Address - Country:US
Practice Address - Phone:815-537-8899
Practice Address - Fax:815-537-8802
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016288225100000X
IA004225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-016288OtherILLINOIS PT LICENSE NO
ILR00891Medicare PIN