Provider Demographics
NPI:1558137125
Name:MOSS, KIRSTIN DIANNE
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:DIANNE
Last Name:MOSS
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 1:7512 VICTOR MENDON RD APT 1
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9749
Mailing Address - Country:US
Mailing Address - Phone:419-572-1890
Mailing Address - Fax:
Practice Address - Street 1:150 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3099
Practice Address - Country:US
Practice Address - Phone:585-760-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist