Provider Demographics
NPI:1073185153
Name:FAIL, KRYSTAL ANNE
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ANNE
Last Name:FAIL
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 1:505 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-1516
Mailing Address - Country:US
Mailing Address - Phone:912-531-0616
Mailing Address - Fax:
Practice Address - Street 1:706 W BARNARD ST
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-3017
Practice Address - Country:US
Practice Address - Phone:812-822-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily