Provider Demographics
NPI:1023165297
Name:CORRISTAN, MAUREEN MARIE (LAT,CSCS,PES-NASM)
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:MARIE
Last Name:CORRISTAN
Suffix:
Gender:F
Credentials:LAT,CSCS,PES-NASM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6457 KAHANA WAY
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34241-5526
Mailing Address - Country:US
Mailing Address - Phone:941-320-6507
Mailing Address - Fax:
Practice Address - Street 1:2750 BAHIA VISTA ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2600
Practice Address - Country:US
Practice Address - Phone:941-330-0606
Practice Address - Fax:941-330-0012
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 5732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer