Provider Demographics
NPI:1194582486
Name:MENJIVAR, KHRISTINNE S (PTA)
Entity type:Individual
Prefix:
First Name:KHRISTINNE
Middle Name:S
Last Name:MENJIVAR
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 1:602 OAK ST
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-3963
Mailing Address - Country:US
Mailing Address - Phone:912-272-2920
Mailing Address - Fax:
Practice Address - Street 1:602 OAK ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3963
Practice Address - Country:US
Practice Address - Phone:912-272-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004004225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant