Provider Demographics
NPI:1295804953
Name:TESDALL, KIRSTEN SWENSEN
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:SWENSEN
Last Name:TESDALL
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 1:249 EGRETS WALK
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8099
Mailing Address - Country:US
Mailing Address - Phone:904-710-0451
Mailing Address - Fax:
Practice Address - Street 1:2255 DUNN AVE STE 207
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4739
Practice Address - Country:US
Practice Address - Phone:904-757-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT15496OtherLICENSE#