Provider Demographics
NPI:1932448693
Name:DAHL, KRISTA LYNN (MA60137540)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNN
Last Name:DAHL
Suffix:
Gender:F
Credentials:MA60137540
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 NE 109TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6176
Mailing Address - Country:US
Mailing Address - Phone:360-828-5411
Mailing Address - Fax:
Practice Address - Street 1:5500 NE 109TH CT
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6176
Practice Address - Country:US
Practice Address - Phone:360-828-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60137540172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker