Provider Demographics
NPI:1548457963
Name:WHITENACK, KRISTIN NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:WHITENACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 S CHIPPEWA LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-5585
Mailing Address - Country:US
Mailing Address - Phone:260-729-1190
Mailing Address - Fax:
Practice Address - Street 1:1800 N WABASH RD STE 200
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1300
Practice Address - Country:US
Practice Address - Phone:765-651-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-30
Last Update Date:2007-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003402A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant