Provider Demographics
NPI:1568865160
Name:SHOOK, KRYSTALL (LMP)
Entity Type:Individual
Prefix:
First Name:KRYSTALL
Middle Name:
Last Name:SHOOK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-4839
Mailing Address - Country:US
Mailing Address - Phone:425-286-2712
Mailing Address - Fax:425-286-2713
Practice Address - Street 1:6214 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-4839
Practice Address - Country:US
Practice Address - Phone:928-304-9229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-27
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60433853225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist