1962867721 NPI number — MRS. KRISTIN LEIGH CLYDE MPT

Table of content: MRS. KRISTIN LEIGH CLYDE MPT (NPI 1962867721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962867721 NPI number — MRS. KRISTIN LEIGH CLYDE MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLYDE
Provider First Name:
KRISTIN
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRESHCORN
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962867721
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
273 ROUTE 288
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLWOOD CITY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16117-3055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-758-7044
Provider Business Mailing Address Fax Number:
724-752-6845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
273 ROUTE 288
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLWOOD CITY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16117-3055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-758-7044
Provider Business Practice Location Address Fax Number:
724-752-6845
Provider Enumeration Date:
12/22/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT015517 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)