Provider Demographics
NPI:1164706586
Name:CLARK, KRISTINA KEHOSKIE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:KEHOSKIE
Last Name:CLARK
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 1:185 OLD MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-1939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 BENNOCH RD
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04473-3620
Practice Address - Country:US
Practice Address - Phone:207-866-0532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0395232251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics