=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669027686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA KVILVANG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2019
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 497 OLDE WATERFORD WAY STE 102
-----------------------------------------------------
City | BELVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28451-4183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-444-1548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 NUTT ST APT 1259
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28401-5392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-861-1309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | P20903
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PTP-PT-LIC-17192
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------