Provider Demographics
NPI:1235601287
Name:CENTENO, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:CENTENO
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 1:2433 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-3157
Mailing Address - Country:US
Mailing Address - Phone:240-308-4897
Mailing Address - Fax:
Practice Address - Street 1:3200 BAKER CIR
Practice Address - Street 2:
Practice Address - City:ADAMSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21710-9653
Practice Address - Country:US
Practice Address - Phone:240-308-4897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4606208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation