Provider Demographics
NPI:1447029137
Name:HENRETTA, KRISTEN E (PTA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:E
Last Name:HENRETTA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 RIMSWELL CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3299
Mailing Address - Country:US
Mailing Address - Phone:804-513-2691
Mailing Address - Fax:
Practice Address - Street 1:2300 CEDARFIELD PKWY
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1936
Practice Address - Country:US
Practice Address - Phone:804-474-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605435225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant