Provider Demographics
NPI:1871927558
Name:CANOSA, KRISTY KEI (DPT)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:KEI
Last Name:CANOSA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:720 12TH ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6708
Practice Address - Country:US
Practice Address - Phone:253-735-3606
Practice Address - Fax:253-351-9807
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60389551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1871927558Medicaid
WA0316219OtherDEPT. OF LABOR AND INDUSTRIES
WA0316219OtherDEPT. OF LABOR AND INDUSTRIES