Basic Information
Provider Information | |||||||||
NPI: | 1831478635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIDELER | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MEYER | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4921 E 21ST ST N | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672081602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166813204 | ||||||||
FaxNumber: | 3166810541 | ||||||||
Practice Location | |||||||||
Address1: | 3500 N ROCK RD STE 101 | ||||||||
Address2: | BUILDING 2200 | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672261341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3164403316 | ||||||||
FaxNumber: | 8889656885 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2011 | ||||||||
LastUpdateDate: | 03/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 211163 | TX | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   | 225X00000X | 17-02953 | KS | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.