Provider Demographics
NPI:1326814138
Name:MIKEK, KRYSTLE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:MIKEK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15621 ELSMERE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-2629
Mailing Address - Country:US
Mailing Address - Phone:301-404-0983
Mailing Address - Fax:
Practice Address - Street 1:15621 ELSMERE CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-2629
Practice Address - Country:US
Practice Address - Phone:301-404-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1048881163W00000X
MDRSS7429163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse