Provider Demographics
NPI:1437582376
Name:CLARK, KRYSTIN
Entity Type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:
Last Name:CLARK
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 1:745 ORIENTA AVE
Mailing Address - Street 2:STE 1015
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5619
Mailing Address - Country:US
Mailing Address - Phone:407-332-7816
Mailing Address - Fax:407-332-6361
Practice Address - Street 1:745 ORIENTA AVE
Practice Address - Street 2:STE 1015
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5619
Practice Address - Country:US
Practice Address - Phone:407-332-7816
Practice Address - Fax:407-332-6361
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA71716225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist