Provider Demographics
NPI:1770116444
Name:LIRETTE, KRISTEN NOELLE
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NOELLE
Last Name:LIRETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:NOELLE
Other - Last Name:HAGAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2326 OVERTON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3446
Mailing Address - Country:US
Mailing Address - Phone:941-812-1309
Mailing Address - Fax:
Practice Address - Street 1:950 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2608
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT014271OtherPT LICENSE