Provider Demographics
NPI:1134885221
Name:LESTOCK, KATLYN
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:LESTOCK
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 1:15508 W BELL RD STE 101-261
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2432
Mailing Address - Country:US
Mailing Address - Phone:623-322-8250
Mailing Address - Fax:
Practice Address - Street 1:13601 N LITCHFIELD RD STE 124
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-4260
Practice Address - Country:US
Practice Address - Phone:623-322-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist