Provider Demographics
NPI:1568767242
Name:ROBINSON, KRISTA JOHNSON (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:JOHNSON
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-3205
Practice Address - Street 1:401 BAPTIST DR STE 306
Practice Address - Street 2:BAPTIST PT-MADISON
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2012
Practice Address - Country:US
Practice Address - Phone:601-607-7204
Practice Address - Fax:601-607-7430
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03680728Medicaid
MS640881013OtherTAX ID NUMBER
MS03680728Medicaid
MS640881013OtherTAX ID NUMBER