Provider Demographics
NPI:1720693005
Name:FISH, KRISTAN LEIGH (DPT)
Entity Type:Individual
Prefix:DR
First Name:KRISTAN
Middle Name:LEIGH
Last Name:FISH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 CANDLE LIGHT DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MD
Mailing Address - Zip Code:21036-1141
Mailing Address - Country:US
Mailing Address - Phone:201-873-8406
Mailing Address - Fax:
Practice Address - Street 1:4050 CANDLE LIGHT DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:MD
Practice Address - Zip Code:21036-1141
Practice Address - Country:US
Practice Address - Phone:201-873-8406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-13
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist