Healthcare Provider Details

I. General information

NPI: 1114964558
Provider Name (Legal Business Name): KRISTI LINN CONWAY DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 PROFESSIONAL PARK DRIVE
BRANDON FL
33511-0000
US

IV. Provider business mailing address

1149 PROFESSIONAL PARK DR
BRANDON FL
33511-4887
US

V. Phone/Fax

Practice location:
  • Phone: 813-685-3668
  • Fax: 813-685-5430
Mailing address:
  • Phone: 813-685-3668
  • Fax: 813-685-5430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2913
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO2913
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: