Healthcare Provider Details

I. General information

NPI: 1497307250
Provider Name (Legal Business Name): CRYSTAL MOKUAU LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 W CLEARWATER AVE STE 12A
KENNEWICK WA
99336-1980
US

IV. Provider business mailing address

5219 W CLEARWATER AVE STE 12A
KENNEWICK WA
99336-1980
US

V. Phone/Fax

Practice location:
  • Phone: 509-540-4921
  • Fax:
Mailing address:
  • Phone: 509-540-4921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60370919
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: