Provider Demographics
NPI:1487973095
Name:CREIGHTON, KEVAN M (ATC)
Entity type:Individual
Prefix:
First Name:KEVAN
Middle Name:M
Last Name:CREIGHTON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4529 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1216
Mailing Address - Country:US
Mailing Address - Phone:414-232-9781
Mailing Address - Fax:
Practice Address - Street 1:4529 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1216
Practice Address - Country:US
Practice Address - Phone:414-232-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1125-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer