Provider Demographics
NPI:1861024366
Name:TAN, KRISTA SHALEE LOOMIS (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA SHALEE
Middle Name:LOOMIS
Last Name:TAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:SHALEE
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7215 W 83RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-2518
Mailing Address - Country:US
Mailing Address - Phone:310-665-0908
Mailing Address - Fax:
Practice Address - Street 1:31248 OAK CREST DR STE 120
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5673
Practice Address - Country:US
Practice Address - Phone:818-926-9057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty