Provider Demographics
NPI:1013417930
Name:BAKER, KRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11015 W ELM LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-8366
Mailing Address - Country:US
Mailing Address - Phone:480-233-4745
Mailing Address - Fax:
Practice Address - Street 1:2301 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5904
Practice Address - Country:US
Practice Address - Phone:602-257-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP047817164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse