Provider Demographics
NPI:1932478963
Name:LEE, KRISTA LEE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEE
Last Name:LEE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 ANTON RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073
Mailing Address - Country:US
Mailing Address - Phone:920-207-2519
Mailing Address - Fax:
Practice Address - Street 1:N7135 ROCKY KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073
Practice Address - Country:US
Practice Address - Phone:920-449-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1420-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1420-19OtherPHYSICAL THERAPIST ASSISTANT LICENSE