Provider Demographics
NPI:1376030460
Name:KIM, KRISTA MARIA (ATC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIA
Last Name:KIM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S ROOSEVELT RD APT 1029
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-1076
Mailing Address - Country:US
Mailing Address - Phone:925-699-1101
Mailing Address - Fax:
Practice Address - Street 1:150 S ROOSEVELT RD APT 1029
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-1076
Practice Address - Country:US
Practice Address - Phone:925-699-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer