Provider Demographics
NPI:1033509526
Name:WESLEY, KRYSTAL MARIE
Entity Type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:MARIE
Last Name:WESLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 HERON DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7928
Mailing Address - Country:US
Mailing Address - Phone:804-615-7156
Mailing Address - Fax:
Practice Address - Street 1:122 HERON DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-7928
Practice Address - Country:US
Practice Address - Phone:804-615-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40405183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician