Provider Demographics
NPI:1003209081
Name:SMITH, KRYSTLE SHANE (SLP)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:SHANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KRYSTLE
Other - Middle Name:SHANE
Other - Last Name:BAUMGARTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15127 81ST ST NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-4558
Mailing Address - Country:US
Mailing Address - Phone:763-688-0353
Mailing Address - Fax:
Practice Address - Street 1:1350 SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-2837
Practice Address - Country:US
Practice Address - Phone:763-688-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist