Provider Demographics
NPI:1306364047
Name:PASTORE, KYANNA (ATC)
Entity Type:Individual
Prefix:
First Name:KYANNA
Middle Name:
Last Name:PASTORE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:BRANCHBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-3505
Mailing Address - Country:US
Mailing Address - Phone:908-448-7037
Mailing Address - Fax:
Practice Address - Street 1:1160 STEELWOOD RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-1356
Practice Address - Country:US
Practice Address - Phone:908-448-7037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL49172255A2300X
OH0059372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer