Provider Demographics
NPI:1982474292
Name:MEDINA, KRISTEN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S JONES BLVD # 2612
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2623
Mailing Address - Country:US
Mailing Address - Phone:702-372-8335
Mailing Address - Fax:
Practice Address - Street 1:1111 S ROOP ST UNIT 2743
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89702-7210
Practice Address - Country:US
Practice Address - Phone:702-372-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.12289225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist