Provider Demographics
NPI:1275880585
Name:NYGAARD, KRISTIANE ELI (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIANE
Middle Name:ELI
Last Name:NYGAARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIANE
Other - Middle Name:ELI
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1568 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2531
Mailing Address - Country:US
Mailing Address - Phone:510-692-0241
Mailing Address - Fax:
Practice Address - Street 1:159 PARROTT ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4813
Practice Address - Country:US
Practice Address - Phone:510-858-0771
Practice Address - Fax:510-201-2503
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist