Basic Information
| Provider Information | |||||||||
| NPI: | 1518506294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STURDEVANT | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11144 AURORA AVE | ||||||||
| Address2: | |||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503227903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152786868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11144 AURORA AVE | ||||||||
| Address2: | |||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503227903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152786868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2019 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 096733 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.