Provider Demographics
NPI:1124913843
Name:KEITH, KRISTY J
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:J
Last Name:KEITH
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 1:1420 S MILLIKEN AVE STE 508
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-2337
Mailing Address - Country:US
Mailing Address - Phone:909-983-2020
Mailing Address - Fax:
Practice Address - Street 1:1420 S MILLIKEN AVE STE 508
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2337
Practice Address - Country:US
Practice Address - Phone:909-983-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20453225X00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist