Provider Demographics
NPI:1851911721
Name:CHINN, CRISTAN NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:CRISTAN
Middle Name:NICOLE
Last Name:CHINN
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 1:851 HARVARD DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3043
Mailing Address - Country:US
Mailing Address - Phone:269-240-1894
Mailing Address - Fax:
Practice Address - Street 1:280 W 40TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4664
Practice Address - Country:US
Practice Address - Phone:616-796-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003849225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant