Provider Demographics
NPI:1538610068
Name:KRYSA, TRACIE JANEANN
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:JANEANN
Last Name:KRYSA
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 1:1917 N COLONY LN
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64058-1311
Mailing Address - Country:US
Mailing Address - Phone:816-806-1961
Mailing Address - Fax:
Practice Address - Street 1:1917 N COLONY LN
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64058-1311
Practice Address - Country:US
Practice Address - Phone:816-806-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant