Provider Demographics
NPI:1467995118
Name:DYMOND-DRAKE, KRISTIN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:DYMOND-DRAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4177
Mailing Address - Country:US
Mailing Address - Phone:732-345-1377
Mailing Address - Fax:
Practice Address - Street 1:174 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4177
Practice Address - Country:US
Practice Address - Phone:732-345-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00602400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist