Provider Demographics
NPI:1639376155
Name:BRANDENBURG, KRISTA ROSE (PT, MS)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:ROSE
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ANN ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1066
Mailing Address - Country:US
Mailing Address - Phone:606-723-5153
Mailing Address - Fax:
Practice Address - Street 1:411 BERTHA WALLACE DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-9418
Practice Address - Country:US
Practice Address - Phone:606-723-5153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist