Healthcare Provider Details

I. General information

NPI: 1861724361
Provider Name (Legal Business Name): KALI KRYSTEN SPEERSTRA LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KALI KRYSTEN WHITE

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10224 S. ELECTRIC AVE.
FOUR LAKES WA
99014
US

IV. Provider business mailing address

PO BOX 131
FOUR LAKES WA
99014
US

V. Phone/Fax

Practice location:
  • Phone: 509-220-4142
  • Fax:
Mailing address:
  • Phone: 509-220-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA 60117477
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60117477
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: