Healthcare Provider Details

I. General information

NPI: 1235775511
Provider Name (Legal Business Name): KRISTA R HEFTY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 W MANSLICK RD
FAIRDALE KY
40118-9581
US

IV. Provider business mailing address

148 CORAL BAY CT APT 1
SHEPHERDSVILLE KY
40165-7974
US

V. Phone/Fax

Practice location:
  • Phone: 502-367-2112
  • Fax: 502-367-0702
Mailing address:
  • Phone: 502-751-2309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number260892
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: