Provider Demographics
NPI:1588282107
Name:HAZLETT, KRISTA V (LMT, MMP)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:V
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11736
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77842-1736
Mailing Address - Country:US
Mailing Address - Phone:970-217-0825
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH AVE E
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77801-4437
Practice Address - Country:US
Practice Address - Phone:832-356-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX125205225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist