Provider Demographics
NPI:1780233049
Name:FARRON, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:FARRON
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 1:1908 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1232
Mailing Address - Country:US
Mailing Address - Phone:269-459-6212
Mailing Address - Fax:269-585-6068
Practice Address - Street 1:3145 W CLARK RD STE 102
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1120
Practice Address - Country:US
Practice Address - Phone:734-619-0193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist