Provider Demographics
NPI:1932635216
Name:SCHUPP, KRISTEN ERIN (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ERIN
Last Name:SCHUPP
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 1:4295 PEARTREE LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2118
Mailing Address - Country:US
Mailing Address - Phone:907-371-0979
Mailing Address - Fax:
Practice Address - Street 1:600 UNIVERSITY AVE
Practice Address - Street 2:SUITE 6D
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3660
Practice Address - Country:US
Practice Address - Phone:907-371-0979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK108914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist