Provider Demographics
NPI:1649466889
Name:PRIDIE, KRISTA LEE (PTA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEE
Last Name:PRIDIE
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 1:25719 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51108-8708
Mailing Address - Country:US
Mailing Address - Phone:712-301-8259
Mailing Address - Fax:
Practice Address - Street 1:1701 W 25TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51103-1705
Practice Address - Country:US
Practice Address - Phone:712-252-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE809225200000X
IA072199225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant