Provider Demographics
NPI:1245768530
Name:WHITE, KRYSTAL (MHPP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 CALVIN AVERY DR STE A
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-6538
Mailing Address - Country:US
Mailing Address - Phone:870-732-1878
Mailing Address - Fax:
Practice Address - Street 1:1712 LINDAUER RD
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2523
Practice Address - Country:US
Practice Address - Phone:870-633-0511
Practice Address - Fax:870-633-0564
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator