=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831366053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTEN E AULT PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 05/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9418 W COUNTY ROAD 300 S
-----------------------------------------------------
City | MEDORA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47260-9709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-521-0054
-----------------------------------------------------
Fax | 812-966-2407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9418 W COUNTY ROAD 300 S
-----------------------------------------------------
City | MEDORA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47260-9709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-521-0054
-----------------------------------------------------
Fax | 812-966-2407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 06003508A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------