Provider Demographics
NPI:1710489885
Name:NAKATA, KRYSTAL MCKINNEY (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MCKINNEY
Last Name:NAKATA
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-2330
Mailing Address - Country:US
Mailing Address - Phone:636-578-0716
Mailing Address - Fax:
Practice Address - Street 1:512 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-2330
Practice Address - Country:US
Practice Address - Phone:636-578-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10459261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy