Provider Demographics
NPI:1366287252
Name:SHELTON, KRISTIN R (OTD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:SHELTON
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7468 N SAINT PAUL DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-9764
Mailing Address - Country:US
Mailing Address - Phone:630-947-6478
Mailing Address - Fax:
Practice Address - Street 1:401 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7108
Practice Address - Country:US
Practice Address - Phone:907-357-2578
Practice Address - Fax:907-357-2529
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK226122225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist