Healthcare Provider Details

I. General information

NPI: 1346274321
Provider Name (Legal Business Name): KRISTIN ANN TIVENER MET, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE
SPRINGFIELD MO
65897-0027
US

IV. Provider business mailing address

901 S NATIONAL AVE
SPRINGFIELD MO
65897-0027
US

V. Phone/Fax

Practice location:
  • Phone: 630-621-0709
  • Fax:
Mailing address:
  • Phone: 630-621-0709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number36001176A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2011013606
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: