Healthcare Provider Details

I. General information

NPI: 1366179947
Provider Name (Legal Business Name): KRYSTAL KIM ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 N LIDGERWOOD ST STE 115
SPOKANE WA
99208-1122
US

IV. Provider business mailing address

107 S DIVISION ST
SPOKANE WA
99202-1510
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-4561
  • Fax:
Mailing address:
  • Phone: 509-838-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61350349
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: