Provider Demographics
NPI:1235961475
Name:LASSITER, KRISTINE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:LASSITER
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 1:6117 SWEET GUM RUN
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-8932
Mailing Address - Country:US
Mailing Address - Phone:863-409-4140
Mailing Address - Fax:
Practice Address - Street 1:6117 SWEET GUM RUN
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-8932
Practice Address - Country:US
Practice Address - Phone:863-409-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA22874235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist