Provider Demographics
NPI:1215088448
Name:KOSTNER, JUSTINA MARIE (PT)
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:MARIE
Last Name:KOSTNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:MARIE
Other - Last Name:THIEME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:323 N MAIN ST
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1335
Mailing Address - Country:US
Mailing Address - Phone:620-532-4480
Mailing Address - Fax:
Practice Address - Street 1:323 N MAIN ST
Practice Address - Street 2:BOX 7
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1335
Practice Address - Country:US
Practice Address - Phone:620-532-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS141138Medicare UPIN