Provider Demographics
NPI:1043330822
Name:BRISTOL, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BRISTOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17052 OLIVE GROVE LANE
Mailing Address - Street 2:
Mailing Address - City:SILVERADO
Mailing Address - State:CA
Mailing Address - Zip Code:92676-9719
Mailing Address - Country:US
Mailing Address - Phone:714-649-0684
Mailing Address - Fax:
Practice Address - Street 1:1045 W REDONDO BEACH BLVD STE 130
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4129
Practice Address - Country:US
Practice Address - Phone:714-523-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CAPT21841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist