Provider Demographics
NPI:1417431842
Name:RITA, KRISHNA
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:RITA
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 1:1462 HARVARD CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2229
Mailing Address - Country:US
Mailing Address - Phone:925-725-5623
Mailing Address - Fax:
Practice Address - Street 1:156 NW CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2492
Practice Address - Country:US
Practice Address - Phone:772-871-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FLPT34815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist