MEDICARE: MS. KRISTY MARIE WALL MASSAGE THERAPIST

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	175F00000X	Naturopath	173821	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	173821	OTHER	OK	MASSAGE LICENSE

General Provider Information

NPI Number	:	1487323143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTY MARIE WALL MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	6221 SE 15TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-2623
Country	:	US
Telephone Number	:	206-380-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	6221 SE 15TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-2623
Country	:	US
Telephone Number	:	206-380-9118
Fax Number	:

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

Provider Enumeration Date	:	09/07/2021
Last Update Date	:	09/07/2021

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