Basic Information
| Provider Information | |||||||||
| NPI: | 1477871176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | SWETLAND | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T., D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SWETLAND | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.T.,D.P.T. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25487 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342772487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413575550 | ||||||||
| FaxNumber: | 8552534836 | ||||||||
| Practice Location | |||||||||
| Address1: | 4351 CORTEZ RD W STE 201 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342103217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413156182 | ||||||||
| FaxNumber: | 9414876233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 25257 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Q08 | 01 | FL | BCBS OF FL | OTHER | Y0M41 | 01 | FL | BCBS | OTHER | 10-6625 | 01 | FL | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 4496768 | 01 | FL | AETNA | OTHER |