Provider Demographics
NPI:1104314905
Name:SHELTON, KRISTA (LMT)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:SHELTON
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 1:1310 CHARTER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-3392
Mailing Address - Country:US
Mailing Address - Phone:810-399-8190
Mailing Address - Fax:
Practice Address - Street 1:10004 E LIPPINCOTT BLVD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-9013
Practice Address - Country:US
Practice Address - Phone:810-399-8190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM503694225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist