Provider Demographics
NPI:1912681040
Name:SOMMERVILLE, KRYSTEN GAYLE (OTR)
Entity type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:GAYLE
Last Name:SOMMERVILLE
Suffix:
Gender:F
Credentials:OTR
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 2654
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:WY
Mailing Address - Zip Code:83128
Mailing Address - Country:US
Mailing Address - Phone:432-770-6257
Mailing Address - Fax:
Practice Address - Street 1:120 W PEARL AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8657
Practice Address - Country:US
Practice Address - Phone:307-734-9129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist