Provider Demographics
NPI:1750881330
Name:REILLY, KRISTEN B (PT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:B
Last Name:REILLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10525 BLAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3103
Mailing Address - Country:US
Mailing Address - Phone:210-488-6306
Mailing Address - Fax:
Practice Address - Street 1:7744 CONNER RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849
Practice Address - Country:US
Practice Address - Phone:865-470-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT4786225100000X
TN12144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM861039695Medicaid