Provider Demographics
NPI:1952570830
Name:NISSEN-ADE, KRYSTAL ANN
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ANN
Last Name:NISSEN-ADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HAUSSLER RD
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841
Mailing Address - Country:US
Mailing Address - Phone:509-826-9600
Mailing Address - Fax:
Practice Address - Street 1:2 HAUSSLER RD
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9591
Practice Address - Country:US
Practice Address - Phone:509-826-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00003418172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist