Provider Demographics
NPI:1144514563
Name:MACCANICO, KRISTIN MARIE (LPTA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:MACCANICO
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-4109
Mailing Address - Country:US
Mailing Address - Phone:702-207-0842
Mailing Address - Fax:702-207-0357
Practice Address - Street 1:2150 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-4109
Practice Address - Country:US
Practice Address - Phone:702-207-0842
Practice Address - Fax:702-207-0357
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2025-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8183225200000X
376J00000X, 3747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider