Provider Demographics
NPI:1295283711
Name:CLAY, KRYSTIN ISELIN (PTA)
Entity type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:ISELIN
Last Name:CLAY
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 1:2106 RAMADA DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-6333
Mailing Address - Country:US
Mailing Address - Phone:760-215-8577
Mailing Address - Fax:
Practice Address - Street 1:2106 RAMADA DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-6333
Practice Address - Country:US
Practice Address - Phone:760-215-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10416225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant