Provider Demographics
NPI:1760355275
Name:REZAEI, KIANNA ALICE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KIANNA
Middle Name:ALICE
Last Name:REZAEI
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 MOUNT ALIFAN PL UNIT C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2802
Mailing Address - Country:US
Mailing Address - Phone:949-812-1027
Mailing Address - Fax:
Practice Address - Street 1:1601 KETTNER BLVD UNIT 11
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2539
Practice Address - Country:US
Practice Address - Phone:619-544-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT308604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist