Provider Demographics
NPI:1174732580
Name:SULLIVAN, KRISTEN KELLY (PT)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:KELLY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 SHELDON ROAD
Mailing Address - Street 2:
Mailing Address - City:ST. ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478
Mailing Address - Country:US
Mailing Address - Phone:802-524-6534
Mailing Address - Fax:802-524-2429
Practice Address - Street 1:596 SHELDON RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-8011
Practice Address - Country:US
Practice Address - Phone:802-524-6534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003571225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist