Provider Demographics
NPI:1780327098
Name:FAIRBANKS, KRISA LYNN (NCBTMB, BCTMB, LMT)
Entity type:Individual
Prefix:
First Name:KRISA
Middle Name:LYNN
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:NCBTMB, BCTMB, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 W 70TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1906
Mailing Address - Country:US
Mailing Address - Phone:612-430-5190
Mailing Address - Fax:
Practice Address - Street 1:8120 PENN AVE S STE 100G
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1368
Practice Address - Country:US
Practice Address - Phone:952-333-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN564285-08225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist