Healthcare Provider Details

I. General information

NPI: 1013564368
Provider Name (Legal Business Name): KRISCYNTHIA OUTLAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6642 E PACIFIC COAST HWY STE 105
LONG BEACH CA
90803-4208
US

IV. Provider business mailing address

6642 E PACIFIC COAST HWY STE 105
LONG BEACH CA
90803-4208
US

V. Phone/Fax

Practice location:
  • Phone: 310-631-2123
  • Fax:
Mailing address:
  • Phone: 310-631-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: