Basic Information
Provider Information | |||||||||
NPI: | 1003299769 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRIBBLE | ||||||||
FirstName: | CHASTITY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18705 126TH AVE NE APT 2721 | ||||||||
Address2: |   | ||||||||
City: | BOTHELL | ||||||||
State: | WA | ||||||||
PostalCode: | 980119349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 22002 64TH AVE W | ||||||||
Address2: | SUITE M11A | ||||||||
City: | MLT | ||||||||
State: | WA | ||||||||
PostalCode: | 98043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2068180028 | ||||||||
FaxNumber: | 4259840112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2015 | ||||||||
LastUpdateDate: | 06/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA60443424 | WA | Y |   | Other Service Providers | Specialist |   |
No ID Information.