Provider Demographics
NPI:1942787007
Name:CHRISTENSEN, KONI (LMT, CHES)
Entity Type:Individual
Prefix:
First Name:KONI
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:F
Credentials:LMT, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13044
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84412-3044
Mailing Address - Country:US
Mailing Address - Phone:208-406-8461
Mailing Address - Fax:
Practice Address - Street 1:5138 W DAY PARK DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2830
Practice Address - Country:US
Practice Address - Phone:208-406-8461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-22
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT22637174H00000X
UT5545539-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty