Basic Information
| Provider Information | |||||||||
| NPI: | 1376530618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMONS | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LELVIS | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32 W GORE ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496151 | ||||||||
| FaxNumber: | 3219436658 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 W GORE ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496151 | ||||||||
| FaxNumber: | 3219436658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 079600 | MI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 52430 | WI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | ME137481 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 250E26047 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | LELVIKRI | 01 | WI | MERCYCARE INSURANCE | OTHER | 101476800 | 05 | FL | MEDICAID | P00772226CD3624 | 01 | WI | RR MEDICARE | OTHER | 4396267 | 05 | MI | MEDICAID |