Healthcare Provider Details

I. General information

NPI: 1225091705
Provider Name (Legal Business Name): KRISTA R BENNETT LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 N CLINTON ST
FORT WAYNE IN
46825-5822
US

IV. Provider business mailing address

726 SUNTURN DR
FORT WAYNE IN
46825-2295
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-8551
  • Fax: 260-484-3351
Mailing address:
  • Phone: 260-497-9529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number36000834A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: