MEDICARE: CHRYSTLE WILLIEFAY WHITE LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	107683	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107683	OTHER	AK	MASSAGE THERAPIST

General Provider Information

NPI Number	:	1366051203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRYSTLE WILLIEFAY WHITE LMT

Provider Business Mailing Address
First Line	:	PO BOX 520794
Second Line	:
City	:	BIG LAKE
State	:	AK
Zip	:	99652-0794
Country	:	US
Telephone Number	:	907-231-6299
Fax Number	:

Provider Business Practice Location Address
First Line	:	12900 W CREEK FRONTAGE RD
Second Line	:
City	:	BIG LAKE
State	:	AK
Zip	:	99623-4880
Country	:	US
Telephone Number	:	907-892-7335
Fax Number	:	907-737-1429

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2020
Last Update Date	:	07/27/2020

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