Provider Demographics
NPI:1073822466
Name:EDWARDS RUELAS, KRYSTAL SHAUNAE (DPT)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:SHAUNAE
Last Name:EDWARDS RUELAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE ATTN:CREDENTIALS
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-1518
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-6613
Practice Address - Country:US
Practice Address - Phone:602-214-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-02
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60354135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist