Provider Demographics
NPI:1669210498
Name:KISTNER, SHONA
Entity type:Individual
Prefix:
First Name:SHONA
Middle Name:
Last Name:KISTNER
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 1:14844 SEA MYRTLE LN
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-3422
Mailing Address - Country:US
Mailing Address - Phone:727-478-5500
Mailing Address - Fax:
Practice Address - Street 1:1900 LAND O LAKES BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-2920
Practice Address - Country:US
Practice Address - Phone:813-436-3558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist