Provider Demographics
NPI:1619170081
Name:PARK, KRISTA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNN
Last Name:PARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 STRAWBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2836
Mailing Address - Country:US
Mailing Address - Phone:860-376-2360
Mailing Address - Fax:
Practice Address - Street 1:16 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374-1036
Practice Address - Country:US
Practice Address - Phone:860-564-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist