=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336737410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHRISTA FORTUNE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2021
-----------------------------------------------------
Last Update Date | 01/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 W NORTHERN LIGHTS BLVD STE C
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-334-8020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 802 N LANE ST APT 4
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99508-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-538-7990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LMT
-----------------------------------------------------
Name | KHRISTA FORTUNE
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 907-538-7990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------