Provider Demographics
NPI:1790882116
Name:FISH, KRISTA ANN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:ANN
Last Name:FISH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1010 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7802
Mailing Address - Country:US
Mailing Address - Phone:920-733-7726
Mailing Address - Fax:920-733-2109
Practice Address - Street 1:3916 N INTERTECH CT
Practice Address - Street 2:SUITE B
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6956
Practice Address - Country:US
Practice Address - Phone:920-733-7726
Practice Address - Fax:920-733-2109
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI632024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6323024OtherLICENSE