Provider Demographics
NPI:1386822161
Name:DENNIS, KRISTA LYN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYN
Last Name:DENNIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8162 GRAY WOLF DR
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-2507
Mailing Address - Country:US
Mailing Address - Phone:315-221-4125
Mailing Address - Fax:
Practice Address - Street 1:830 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4034
Practice Address - Country:US
Practice Address - Phone:315-785-4088
Practice Address - Fax:315-786-4847
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013638-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist