Provider Demographics
NPI:1043937402
Name:VILLAMAYOR, KRYSTLE ANN
Entity Type:Individual
Prefix:
First Name:KRYSTLE ANN
Middle Name:
Last Name:VILLAMAYOR
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 1:4640 RIDDLE DR
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7106 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3875
Practice Address - Country:US
Practice Address - Phone:410-866-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2883152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty