Provider Demographics
NPI:1114560588
Name:RODRIGUEZ, KRYSTLE (PTA)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:RODRIGUEZ
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 1:4406 E WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0123
Mailing Address - Country:US
Mailing Address - Phone:480-512-1314
Mailing Address - Fax:
Practice Address - Street 1:8008 S JESSE OWENS PKWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6516
Practice Address - Country:US
Practice Address - Phone:602-243-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10532A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant