Provider Demographics
NPI:1831457449
Name:PRATT, KRYSTAL GAYLE (LMP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:GAYLE
Last Name:PRATT
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 1:2603 BRIDGEPORT WAY W
Mailing Address - Street 2:STE J
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4724
Mailing Address - Country:US
Mailing Address - Phone:253-753-7522
Mailing Address - Fax:
Practice Address - Street 1:2603 BRIDGEPORT WAY W
Practice Address - Street 2:STE J
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4724
Practice Address - Country:US
Practice Address - Phone:253-753-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60285290225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist