Provider Demographics
NPI:1215331939
Name:BRISTOW, KATRINA (LMT)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 CALL FIELD RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2516
Mailing Address - Country:US
Mailing Address - Phone:940-733-9168
Mailing Address - Fax:940-723-6592
Practice Address - Street 1:4111 CALL FIELD RD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2516
Practice Address - Country:US
Practice Address - Phone:940-733-9168
Practice Address - Fax:940-723-6592
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist