Provider Demographics
NPI:1780468025
Name:SULLIVAN, KRYSTA (DPT)
Entity type:Individual
Prefix:
First Name:KRYSTA
Middle Name:
Last Name:SULLIVAN
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 1:2045 E BOSTON ST APT 4070
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1857
Mailing Address - Country:US
Mailing Address - Phone:714-851-3139
Mailing Address - Fax:
Practice Address - Street 1:36397 N GANTZEL RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7336
Practice Address - Country:US
Practice Address - Phone:480-567-2987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist