=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780327098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISA LYNN FAIRBANKS NCBTMB, BCTMB, LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2022
-----------------------------------------------------
Last Update Date | 04/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8120 PENN AVE S STE 100G
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-1368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-333-4644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 W 70TH ST
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55423-1906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-430-5190
-----------------------------------------------------
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 | 564285-08
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------