Provider Demographics
NPI:1477803161
Name:BLYTHE, KRISTINA LORRAINE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:LORRAINE
Last Name:BLYTHE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:LORRAINE
Other - Last Name:JAROSZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:560 DELAWARE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1212
Mailing Address - Country:US
Mailing Address - Phone:716-682-6201
Mailing Address - Fax:
Practice Address - Street 1:4650 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075
Practice Address - Country:US
Practice Address - Phone:716-646-7424
Practice Address - Fax:716-312-3001
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031612-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist