Provider Demographics
NPI:1093291882
Name:GASTON, KILANI KRISTEN (DPT)
Entity type:Individual
Prefix:
First Name:KILANI
Middle Name:KRISTEN
Last Name:GASTON
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 1:1991 FORDHAM DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3774
Mailing Address - Country:US
Mailing Address - Phone:910-484-4653
Mailing Address - Fax:910-483-9256
Practice Address - Street 1:1991 FORDHAM DR STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3774
Practice Address - Country:US
Practice Address - Phone:910-484-4653
Practice Address - Fax:910-483-9256
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017948225100000X
GACP014581T225100000X
IL70027817225100000X
NCCP034812T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist