Provider Demographics
NPI:1912307182
Name:KISTAMPALLY, EDANA (OTR/L)
Entity Type:Individual
Prefix:
First Name:EDANA
Middle Name:
Last Name:KISTAMPALLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 EAGLE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:PENRYN
Mailing Address - State:CA
Mailing Address - Zip Code:95663-9623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:790 LETICA DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1581
Practice Address - Country:US
Practice Address - Phone:408-854-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA326444225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist