Provider Demographics
NPI:1467648667
Name:MIRACLE, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MIRACLE
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 1:2316 OCRACOKE ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17202-7422
Mailing Address - Country:US
Mailing Address - Phone:717-660-2730
Mailing Address - Fax:717-446-0526
Practice Address - Street 1:25 PENNCRAFT AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-5600
Practice Address - Country:US
Practice Address - Phone:717-660-2730
Practice Address - Fax:717-446-0526
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004139L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist