Provider Demographics
NPI:1699215046
Name:THOMPSON, KRISTEN NICOLE (PTA)
Entity type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:NICOLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10726 ROXBURY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8628
Mailing Address - Country:US
Mailing Address - Phone:704-349-1027
Mailing Address - Fax:
Practice Address - Street 1:3800 SHAMROCK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-3220
Practice Address - Country:US
Practice Address - Phone:704-532-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant