Provider Demographics
NPI:1215153804
Name:SANDERSON, CRYSTAL (LMT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:SANDERSON
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 1:29509 196TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-9222
Mailing Address - Country:US
Mailing Address - Phone:206-949-0581
Mailing Address - Fax:
Practice Address - Street 1:22226 6TH AVE S STE 101
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6246
Practice Address - Country:US
Practice Address - Phone:206-824-7200
Practice Address - Fax:206-824-7720
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist