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General NPI Number Information
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NPI Number | 1043460413
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Entity Type | Individual
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Provider Name | KRIS AVERELL MSOTR/L
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Gender | Female
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Dates
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Enumeration Date | 09/23/2008
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Last Update Date | 09/23/2008
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Provider Practice Location Address
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Address Line | 3103 RIDGEMOOR CT
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City | PROSPECT
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State | KY
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Zip | 40059-8111
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Country | US
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Telephone | 502-228-5776
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Fax |
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Provider Business Mailing Address
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Address Line | 3103 RIDGEMOOR CT
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City | PROSPECT
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State | KY
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Zip | 40059-8111
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Country | US
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Telephone | 502-228-5776
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | KY-R3826
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License Number State | KY
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