1962739813 NPI number — KRYSTAL HALL MEDICAL PROFESSIONAL, PLLC

Table of content: (NPI 1962739813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962739813 NPI number — KRYSTAL HALL MEDICAL PROFESSIONAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRYSTAL HALL MEDICAL PROFESSIONAL, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962739813
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 S BLUE ANGEL PKWY # 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32506-6045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-456-4082
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6984 PINE FOREST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32526-8908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-456-4082
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
KRYSTAL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
850-529-7932

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP3248772 , 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: 109378100 . 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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