Provider Demographics
NPI:1225091705
Name:BENNETT, KRISTA R (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 SUNTURN DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2295
Mailing Address - Country:US
Mailing Address - Phone:260-497-9529
Mailing Address - Fax:
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5822
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-484-3351
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000834A204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine