Healthcare Provider Details

I. General information

NPI: 1710233770
Provider Name (Legal Business Name): KRISTEN HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 NORTH FLETCHER AVENUE
MAYO FL
32066
US

IV. Provider business mailing address

PO BOX 853
MAYO FL
32066-0853
US

V. Phone/Fax

Practice location:
  • Phone: 386-208-2089
  • Fax:
Mailing address:
  • Phone: 386-208-2089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA65228
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: