Provider Demographics
NPI:1225713472
Name:ANDERSON, KRYSTLE FAWN
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:FAWN
Last Name:ANDERSON
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 1:2467 S BURRELL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1562
Mailing Address - Country:US
Mailing Address - Phone:414-627-6668
Mailing Address - Fax:
Practice Address - Street 1:17040 W GREENFIELD AVE STE 6
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6844
Practice Address - Country:US
Practice Address - Phone:262-439-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty