Provider Demographics
NPI:1790490910
Name:SAMRA, KRISTY ANN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:ANN
Last Name:SAMRA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 HOSLER RD
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9541
Mailing Address - Country:US
Mailing Address - Phone:260-418-9935
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011821A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist