Provider Demographics
NPI:1659610327
Name:MASON, KRYSTLE
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:MILLIKEN
Mailing Address - State:CO
Mailing Address - Zip Code:80543-0189
Mailing Address - Country:US
Mailing Address - Phone:970-576-5193
Mailing Address - Fax:
Practice Address - Street 1:112 N IRENE AVE
Practice Address - Street 2:UNIT A
Practice Address - City:MILLIKEN
Practice Address - State:CO
Practice Address - Zip Code:80543-0189
Practice Address - Country:US
Practice Address - Phone:970-576-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 374J00000X
COMT.0016811225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174H00000XOther Service ProvidersHealth Educator
No374J00000XNursing Service Related ProvidersDoula