Provider Demographics
NPI:1245439934
Name:MOON, KRISTY (PTA)
Entity type:Individual
Prefix:MISS
First Name:KRISTY
Middle Name:
Last Name:MOON
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 1:3258 OVERLAND AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3583
Mailing Address - Country:US
Mailing Address - Phone:310-903-2524
Mailing Address - Fax:
Practice Address - Street 1:3258 OVERLAND AVE APT 8
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3583
Practice Address - Country:US
Practice Address - Phone:310-903-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6798225200000X
WYPTA-481225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant