Provider Demographics
NPI:1881101194
Name:SHAMILOVA, KRISTINA (LMT)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SHAMILOVA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8324 REGENTS RD UNIT 3O
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1330
Mailing Address - Country:US
Mailing Address - Phone:619-665-2590
Mailing Address - Fax:
Practice Address - Street 1:5575 RUFFIN RD STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1361
Practice Address - Country:US
Practice Address - Phone:858-492-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72859225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist