=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619749223
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTAL DINNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2023
-----------------------------------------------------
Last Update Date | 10/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2412 E 14TH ST FL 1
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-422-1370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2412 E 14TH ST FL 1
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-422-1370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 031908
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------