1134753825 NPI number — KRYSTLE MICHELLE WISNASKY FNP-BC

Table of content: KRYSTLE MICHELLE WISNASKY FNP-BC (NPI 1134753825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134753825 NPI number — KRYSTLE MICHELLE WISNASKY FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISNASKY
Provider First Name:
KRYSTLE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
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:
1134753825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63178-4369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-567-6071
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6812 STATE ROUTE 162 STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062-8562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-288-0900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2020

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: 363LF0000X , with the licence number:  209.020939 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 209.020939 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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