Provider Demographics
NPI:1033674460
Name:SMITH, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17419 BRIDGE HILL CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3599
Mailing Address - Country:US
Mailing Address - Phone:813-907-7879
Mailing Address - Fax:813-994-3080
Practice Address - Street 1:17419 BRIDGE HILL CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3599
Practice Address - Country:US
Practice Address - Phone:813-907-7879
Practice Address - Fax:813-994-3080
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FL34154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist