Provider Demographics
NPI:1124688403
Name:MILLIETTE, KRISTIN (ATC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MILLIETTE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41984
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85717-1984
Mailing Address - Country:US
Mailing Address - Phone:509-699-0148
Mailing Address - Fax:
Practice Address - Street 1:565 N CHERRY AVE
Practice Address - Street 2:LSFF ATHLETIC TRAINING ROOM
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719
Practice Address - Country:US
Practice Address - Phone:509-699-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0089312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer