Provider Demographics
NPI:1518506294
Name:STURDEVANT, KRISTINA ANN
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ANN
Last Name:STURDEVANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11144 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-7903
Mailing Address - Country:US
Mailing Address - Phone:515-278-6868
Mailing Address - Fax:
Practice Address - Street 1:11144 AURORA AVE
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-7903
Practice Address - Country:US
Practice Address - Phone:515-278-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096733225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant