Provider Demographics
NPI:1548400732
Name:RISTAU, KIMBERLY NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:RISTAU
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:SAXMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3266 FLUVANNA AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:FLUVANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9706
Mailing Address - Country:US
Mailing Address - Phone:814-688-6119
Mailing Address - Fax:
Practice Address - Street 1:3266 FLUVANNA AVENUE EXT
Practice Address - Street 2:
Practice Address - City:FLUVANNA
Practice Address - State:NY
Practice Address - Zip Code:14701-9706
Practice Address - Country:US
Practice Address - Phone:814-688-6119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209156225100000X
PA019695225100000X
NY031194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03100832Medicaid
NY03100832Medicaid