Provider Demographics
NPI:1679132641
Name:CONTI, KRISTINA STORM
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:STORM
Last Name:CONTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4578 WADE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-5845
Mailing Address - Country:US
Mailing Address - Phone:770-815-6534
Mailing Address - Fax:
Practice Address - Street 1:4640 MARTIN RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5542
Practice Address - Country:US
Practice Address - Phone:678-679-1261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003220548AMedicaid