Provider Demographics
NPI:1538947387
Name:LAGESON, KRISTY NICOLE
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:NICOLE
Last Name:LAGESON
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 1:18197 ROYAL WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-9095
Mailing Address - Country:US
Mailing Address - Phone:425-471-1603
Mailing Address - Fax:
Practice Address - Street 1:1159 E IRON EAGLE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6871
Practice Address - Country:US
Practice Address - Phone:425-471-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4406225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist