Provider Demographics
NPI:1477579324
Name:LAKE, KRISTY ANN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:ANN
Last Name:LAKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 3RD ST S
Mailing Address - Street 2:#613
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4356 66TH ST N
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-4920
Practice Address - Country:US
Practice Address - Phone:727-546-4700
Practice Address - Fax:727-549-8108
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist