Provider Demographics
NPI:1487323143
Name:WALL, KRISTY MARIE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:MARIE
Last Name:WALL
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 1:6221 SE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2623
Mailing Address - Country:US
Mailing Address - Phone:206-380-9118
Mailing Address - Fax:
Practice Address - Street 1:6221 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2623
Practice Address - Country:US
Practice Address - Phone:206-380-9118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK173821175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK173821OtherMASSAGE LICENSE