Provider Demographics
NPI:1124654835
Name:GEARHART, KRISTA RENEA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:RENEA
Last Name:GEARHART
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 1:2480 E MCEWAN PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-9678
Mailing Address - Country:US
Mailing Address - Phone:360-401-9858
Mailing Address - Fax:
Practice Address - Street 1:520 E MEYER LAKE DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7412
Practice Address - Country:US
Practice Address - Phone:360-490-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child