Provider Demographics
NPI:1760690085
Name:BAXTER, KRYSTA L (LMP)
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:L
Last Name:BAXTER
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 1:7620 194TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8511
Mailing Address - Country:US
Mailing Address - Phone:253-891-1081
Mailing Address - Fax:
Practice Address - Street 1:19820 STATE ROUTE 410 E
Practice Address - Street 2:SUITE 201
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6377
Practice Address - Country:US
Practice Address - Phone:253-863-7510
Practice Address - Fax:253-863-5970
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020406225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist