Provider Demographics
NPI:1518644152
Name:LOOMIS, KRISTEN COLLEEN (MA61438025)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:COLLEEN
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:MA61438025
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 106TH PL SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3916
Mailing Address - Country:US
Mailing Address - Phone:425-626-6857
Mailing Address - Fax:
Practice Address - Street 1:10117 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3425
Practice Address - Country:US
Practice Address - Phone:425-806-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61438025225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist