Provider Demographics
NPI:1366785784
Name:FITZGERALD, KRISTIN LEE (PTA)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LEE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:LEE
Other - Last Name:WEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:613 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MO
Mailing Address - Zip Code:65281-1467
Mailing Address - Country:US
Mailing Address - Phone:660-833-9053
Mailing Address - Fax:
Practice Address - Street 1:29080 MUNCAS AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MO
Practice Address - Zip Code:65281-2381
Practice Address - Country:US
Practice Address - Phone:660-833-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2094950225200000X
MO2013001404225200000X
KS14-02490225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant