Provider Demographics
NPI:1699186726
Name:PRUSAK, KRISTA MICHELLE (ATC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MICHELLE
Last Name:PRUSAK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 E 1610 S
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-8921
Mailing Address - Country:US
Mailing Address - Phone:801-310-9987
Mailing Address - Fax:
Practice Address - Street 1:3026 E 1610 S
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-8921
Practice Address - Country:US
Practice Address - Phone:801-310-9987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7479128-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer