Provider Demographics
NPI:1497188825
Name:BONENFANT, KRISTIN ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ROSE
Last Name:BONENFANT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ROSE
Other - Last Name:DANIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:33 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2603
Practice Address - Country:US
Practice Address - Phone:207-828-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1497188825Medicaid