Provider Demographics
NPI:1902093495
Name:FITZGERALD, KRISTINA (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:EDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:721 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4430
Mailing Address - Country:US
Mailing Address - Phone:401-946-4250
Mailing Address - Fax:401-275-5645
Practice Address - Street 1:721 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4430
Practice Address - Country:US
Practice Address - Phone:401-946-4250
Practice Address - Fax:401-275-5645
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01728225100000X
RIAT001762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1902093495OtherRI BLUE CROSS
RI1902093495OtherRI BLUE CROSS