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NPI Code Detail

MEDICARE: KRYSTAL GRACE KENNEDY PT, DPT

MEDICARE: KRYSTAL GRACE KENNEDY PT, DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist10166MN

General Provider Information

NPI Number : 1124962857
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRYSTAL GRACE KENNEDY PT, DPT
Provider Business Mailing Address
First Line : 1210 WILLMAR AVE SE
Second Line :
City : WILLMAR
State : MN
Zip : 56201-4716
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 901 WILLMAR AVE SE
Second Line :
City : WILLMAR
State : MN
Zip : 56201-4604
Country : US
Telephone Number : 320-235-9532
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/15/2026
Last Update Date : 04/15/2026

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