=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831478635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN SHIDELER OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2011
-----------------------------------------------------
Last Update Date | 03/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 N ROCK RD STE 101 BUILDING 2200
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-1341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-440-3316
-----------------------------------------------------
Fax | 888-965-6885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4921 E 21ST ST N
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67208-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-681-3204
-----------------------------------------------------
Fax | 316-681-0541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 211163
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 17-02953
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------