Provider Demographics
NPI:1417657990
Name:STEPHENS, KRYSTAL MICHELLE
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MICHELLE
Last Name:STEPHENS
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 1:1423 TRAYMORE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-1633
Mailing Address - Country:US
Mailing Address - Phone:469-942-7399
Mailing Address - Fax:
Practice Address - Street 1:1423 TRAYMORE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-1633
Practice Address - Country:US
Practice Address - Phone:469-942-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX922461575OtherDELIVER TO CARE LLC