1104163138 NPI number — KRYSTAL JANE NEWBERN D.P.T.

Table of content: KRYSTAL JANE NEWBERN D.P.T. (NPI 1104163138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104163138 NPI number — KRYSTAL JANE NEWBERN D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEWBERN
Provider First Name:
KRYSTAL
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104163138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6500 BOWDEN RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-8070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-634-0640
Provider Business Mailing Address Fax Number:
904-634-0203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-5571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-634-0640
Provider Business Practice Location Address Fax Number:
904-634-0203
Provider Enumeration Date:
01/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT27788 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105772800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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