Provider Demographics
NPI:1811474331
Name:HAKE, KRYSTEIA (LPN)
Entity type:Individual
Prefix:
First Name:KRYSTEIA
Middle Name:
Last Name:HAKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KRYSTEIA
Other - Middle Name:
Other - Last Name:HAKE-PURDUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2316
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:615 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-3522
Practice Address - Country:US
Practice Address - Phone:360-532-4357
Practice Address - Fax:360-538-0124
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60004963164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse