Provider Demographics
NPI:1336738491
Name:PETERSON, KRISTEN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-2105
Mailing Address - Country:US
Mailing Address - Phone:770-880-1929
Mailing Address - Fax:
Practice Address - Street 1:1100 CIRCLE 75 PKWY SE STE 1400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3067
Practice Address - Country:US
Practice Address - Phone:678-403-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0033952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT003395OtherATC LICENSE