Basic Information
| Provider Information | |||||||||
| NPI: | 1952696890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3214 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324053337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508190709 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6012 MAGNOLIA BEACH RD | ||||||||
| Address2: | VILLA 602 | ||||||||
| City: | PANAMA CITY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324087065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502301802 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA19860 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.