Provider Demographics
NPI:1326416751
Name:WILSON, KRYSTAL I
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:WILSON
Suffix:I
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 1:1745 OATES DR
Mailing Address - Street 2:APT 717
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-8801
Mailing Address - Country:US
Mailing Address - Phone:214-916-9524
Mailing Address - Fax:
Practice Address - Street 1:1745 OATES DR
Practice Address - Street 2:APT 717
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-8801
Practice Address - Country:US
Practice Address - Phone:214-916-9524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker