Provider Demographics
NPI:1669022935
Name:BOUTWELL, KIRSTIE JONES (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:JONES
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SPRING CIR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-4820
Mailing Address - Country:US
Mailing Address - Phone:904-412-1524
Mailing Address - Fax:
Practice Address - Street 1:3300 SIEGEL RD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-5844
Practice Address - Country:US
Practice Address - Phone:615-904-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000018092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer