Basic Information
| Provider Information | |||||||||
| NPI: | 1861663023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLL | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAVEL | ||||||||
| OtherFirstName: | KRISTIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PROPHETSTOWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612771105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155378899 | ||||||||
| FaxNumber: | 8155378802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-016288 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 004225 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070-016288 | 01 | IL | ILLINOIS PT LICENSE NO | OTHER |