Provider Demographics
NPI:1982241972
Name:DE LA RUA, KRISTEN MONIQUE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MONIQUE
Last Name:DE LA RUA
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 1:570 NE 64TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-6149
Mailing Address - Country:US
Mailing Address - Phone:305-975-1201
Mailing Address - Fax:
Practice Address - Street 1:7600 SW 57TH AVE STE 304
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5427
Practice Address - Country:US
Practice Address - Phone:305-663-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41588225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist