Healthcare Provider Details

I. General information

NPI: 1427480862
Provider Name (Legal Business Name): KRISTINA LEE SHINN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 OLDE OAKS CIR
MAGNOLIA AR
71753-9322
US

IV. Provider business mailing address

3 OLDE OAKS CIR
MAGNOLIA AR
71753-9322
US

V. Phone/Fax

Practice location:
  • Phone: 870-904-2301
  • Fax:
Mailing address:
  • Phone: 870-904-2301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2718
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: