Provider Demographics
NPI:1790002277
Name:YANG, KRISTEN (5/2009)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:YANG
Suffix:
Gender:F
Credentials:5/2009
Other - Prefix:
Other - First Name:KIA
Other - Middle Name:
Other - Last Name:VANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:543 COON RAPIDS BLVD NW STE B
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5548
Mailing Address - Country:US
Mailing Address - Phone:612-298-5525
Mailing Address - Fax:763-432-0648
Practice Address - Street 1:543 COON RAPIDS BLVD NW STE B
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5548
Practice Address - Country:US
Practice Address - Phone:612-298-5525
Practice Address - Fax:763-432-0648
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2010-140225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist