Provider Demographics
NPI:1235486069
Name:KILLOM, KRYSTAL CAMERON (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:CAMERON
Last Name:KILLOM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:HAYNIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:314 PROSPERITY RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4710
Mailing Address - Country:US
Mailing Address - Phone:865-691-8011
Mailing Address - Fax:865-531-6587
Practice Address - Street 1:314 PROSPERITY RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4710
Practice Address - Country:US
Practice Address - Phone:865-691-8011
Practice Address - Fax:865-531-6587
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16868363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1035I01566Medicare PIN