Provider Demographics
NPI:1164887097
Name:EMANUELSON, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:EMANUELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINE'S
Other - Middle Name:
Other - Last Name:MASSAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:3738 LITTLE ROCK LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5310
Mailing Address - Country:US
Mailing Address - Phone:801-615-1047
Mailing Address - Fax:
Practice Address - Street 1:280 RIVER PARK DR
Practice Address - Street 2:SUITE 240
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5764
Practice Address - Country:US
Practice Address - Phone:801-615-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X
UT217972-4701174H00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No174H00000XOther Service ProvidersHealth Educator