Healthcare Provider Details

I. General information

NPI: 1427044189
Provider Name (Legal Business Name): KRISTINE M VILLARTA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KRISTINE BOMEDIANO

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SAINT PATRICKS DR SUITE 401
WALDORF MD
20603-4527
US

IV. Provider business mailing address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

V. Phone/Fax

Practice location:
  • Phone: 301-870-6717
  • Fax: 301-870-7366
Mailing address:
  • Phone: 301-870-7001
  • Fax: 302-870-6697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21032
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305213251
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: