Provider Demographics
NPI:1376871590
Name:BRANDON, KRISTINA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:BRANDON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:MARIE
Other - Last Name:BRANDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:2412 CUMING ST
Mailing Address - Street 2:STE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-1600
Mailing Address - Country:US
Mailing Address - Phone:402-717-3751
Mailing Address - Fax:
Practice Address - Street 1:1690 US HIGHWAY 1 S
Practice Address - Street 2:SUITE A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4192
Practice Address - Country:US
Practice Address - Phone:904-810-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-29
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist