Provider Demographics
NPI:1881022424
Name:COLLYMORE, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:COLLYMORE
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 1:11 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07396
Mailing Address - Country:US
Mailing Address - Phone:973-887-9000
Mailing Address - Fax:973-887-3816
Practice Address - Street 1:769 NORTHFIELD AVE
Practice Address - Street 2:SUITE 132
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-669-3500
Practice Address - Fax:973-669-3444
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01504700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist