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NPI Code Detail

MEDICARE: KRISTIN CHARLESTON PTA

MEDICARE: KRISTIN CHARLESTON PTA
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
1225200000XPhysical Therapy Assistant160.007379IL

General Provider Information

NPI Number : 1447898671
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTIN CHARLESTON PTA
Provider Business Mailing Address
First Line : 25117 SW PARKWAY AVE STE D
Second Line :
City : WILSONVILLE
State : OR
Zip : 97070-9697
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 414 S WESLEY AVE
Second Line :
City : MOUNT MORRIS
State : IL
Zip : 61054-1428
Country : US
Telephone Number : 815-734-4103
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/18/2019
Last Update Date : 12/18/2019

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Directions to “ KRISTIN CHARLESTON PTA” Practice Location

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