Provider Demographics
NPI:1659906626
Name:COSTON, KYLIE ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:ELIZABETH
Last Name:COSTON
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 1:3149 CASSIUS CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3333
Mailing Address - Country:US
Mailing Address - Phone:907-351-5438
Mailing Address - Fax:
Practice Address - Street 1:3149 CASSIUS CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3333
Practice Address - Country:US
Practice Address - Phone:907-351-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK135111225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist