Provider Demographics
NPI:1730395799
Name:SHOPE, KRYSTAL LYNN (LMP)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:LYNN
Last Name:SHOPE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S CHEHALIS ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2957
Mailing Address - Country:US
Mailing Address - Phone:360-537-5914
Mailing Address - Fax:360-532-1059
Practice Address - Street 1:104 S CHEHALIS ST
Practice Address - Street 2:SUITE 4
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2957
Practice Address - Country:US
Practice Address - Phone:360-537-5914
Practice Address - Fax:360-532-1059
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019187225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602365171OtherUBI
WA403369-00OtherNATIONAL CERTIFICATION #
WA026245OtherABERDEEN CITY LICENCE #
WAMA00019187OtherSTATE LICENCE #