Provider Demographics
NPI:1235509860
Name:MAYNES, KRISTIN AUDRA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:AUDRA
Last Name:MAYNES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 TAMARACK AVE
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3419
Mailing Address - Country:US
Mailing Address - Phone:760-521-1874
Mailing Address - Fax:
Practice Address - Street 1:227 N EL CAMINO REAL
Practice Address - Street 2:SUITE 103
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2807
Practice Address - Country:US
Practice Address - Phone:760-230-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist