Provider Demographics
NPI:1265197438
Name:NIEMANN, KRISTIN (PTA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:NIEMANN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:4961 N FORTVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8637
Mailing Address - Country:US
Mailing Address - Phone:618-623-6126
Mailing Address - Fax:
Practice Address - Street 1:8505 WOODFIELD CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-4309
Practice Address - Country:US
Practice Address - Phone:317-396-8019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004966A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant