Provider Demographics
NPI:1548631856
Name:TYSON, KRISTINA BERNARD
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:BERNARD
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:LEIGH
Other - Last Name:BERNARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:8 SAN CARLOS AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2220
Mailing Address - Country:US
Mailing Address - Phone:504-736-9927
Mailing Address - Fax:
Practice Address - Street 1:12221 SOUTH CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121
Practice Address - Country:US
Practice Address - Phone:504-736-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2000142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer