Provider Demographics
NPI:1336718733
Name:MITCHELL, KRISTA MARIE (PTA, CLT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PTA, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17247 HORIZON TRL SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3939
Mailing Address - Country:US
Mailing Address - Phone:701-320-9793
Mailing Address - Fax:
Practice Address - Street 1:6200 XERXES AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55423-1033
Practice Address - Country:US
Practice Address - Phone:701-320-9793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1539225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant