Provider Demographics
NPI:1104443738
Name:LAFFERTY, KRYSTAL (PTA)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:
Last Name:LAFFERTY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6047 S MAIN STREET RD
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-9178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6047 S MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-9178
Practice Address - Country:US
Practice Address - Phone:812-890-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004091A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty