Provider Demographics
NPI:1487128336
Name:RIZZA, KESTRA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KESTRA
Middle Name:
Last Name:RIZZA
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ROBERT EGLY DR
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46065-9664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ROBERT EGLY DR
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46065-9664
Practice Address - Country:US
Practice Address - Phone:925-708-7829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN36003503A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36003503AOtherINDIANA ATHLETIC TRAINING LICENSURE
2000041072OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER